"Handbook detailing exactly what to document in any situation for nurses in all practice settings. Over 300 alphabetically organized topics cover diseases, emergencies, procedures, legal and ethical problems, and difficult situations involving patients, families and other health care professionals. Legal casebook"-- ChartSmart offers you clear-cut guidelines on documenting the significant events associated with: common and uncommon health problems, from asthma and Dressler's syndrome to latex hypersensitivity and transient ischemic attacks; major emergencies, such as drug overdose, GI hemorrhage, acute myocardial infarction, and shock; critical procedures, from blood transfusions and endotracheal tube insertion to pacemaker care and seizure management; potential ethical and legal pitfalls, such as collecting blood as evidence, questioning a doctor's order, using restraints, and more; difficult situations involving patients (such as dealing with hostile threats), families (such as responding to the presence of firearms in the home), and health care team members (such as reporting illegal alterations of medical records). -- Provided by publisher. Provided by publisher.

Preceded by Chart smart. 3rd ed. c2011.

Documentation (in alphabetical order) -- A -- Abuse, Suspected -- Activities of Daily Living -- Advance Directive -- Advice to Patient by Telephone -- Against Medical Advice, Discharge -- Against Medical Advice, Out of Bed -- Alcohol Found at Bedside -- Allergy Testing -- Anaphylaxis -- Arrhythmias -- Arterial Blood Sampling -- Arterial Line Insertion -- Arterial Line Removal -- Arterial Occlusion, Acute -- Arterial Pressure Monitoring -- Arthroplasty Care -- Aspiration, Foreign Body -- Aspiration, Tube Feeding -- Assessment, Initial -- Asthma -- B -- Bladder Irrigation, Continuous -- Blank Spaces in Chart or Flow Sheet -- Blood Transfusion -- Blood Transfusion Reaction -- Bone Marrow Aspiration and Biopsy -- Brain Death -- Burns, Assessment and Nursing Care -- C -- Cardiac Monitoring (Telemetry) -- Cardiac Tamponade -- Cardiopulmonary Arrest and Resuscitation -- Cardioversion, Synchronized -- Caregiver Strain -- Care Plan, Traditional -- Cast Care -- Central Venous Access Device Insertion -- Central Venous Access Device Occlusion -- Central Venous Access Device Removal -- Central Venous Access Device Site Care -- Central Venous Pressure Monitoring -- Chest Pain -- Chest Tube Care -- Chest Tube Insertion -- Chest Tube Removal -- Chest Tube Removal by Patient -- Clinical Pathway -- Cold Therapy Application -- Confusion -- Continuous Renal Replacement Therapy -- Correction to Documentation -- Critical Test Values, Reporting -- Cultural Needs Identification -- D -- Death of a Patient -- Dehydration, Acute -- Dementia -- Diabetic Ketoacidosis -- Discharge Instructions -- Do-Not-Resuscitate Order -- Computerized Physician Order Entry (Formerly Called Doctor's Orders) -- Health Care Provider's Orders, Telephone -- Health Care Provider's Orders, Verbal -- Drug Administration -- Drug Administration, Adverse Effects of -- Drug Administration, One-Time Dose -- Drug Administration, Opioid -- Drug Administration, Stat Order -- Drug Administration, Withholding Ordered Drug -- Drugs, Illegal -- Drugs, Inappropriate Use of -- Drugs, Patient Hiding -- Drugs, Patient Refusal to Take -- Dyspnea -- E -- Elopement from a Health Care Facility -- Emergency Treatment, Patient Refusal of -- End-of-Life Care -- Endotracheal Extubation -- Endotracheal Intubation -- Endotracheal Tube, Patient Removal of -- End-Tidal Carbon Dioxide Monitoring -- Enema Administration -- Epidural Analgesia -- Epidural Hematoma -- Esophageal Tube Insertion (Sengstaken-Blakemore Tube) -- Esophageal Tube Removal -- Experimental Procedures -- F -- Failure to Provide Information -- Falls, Patient -- Falls, Precautions -- Falls, Visitor or Other -- Firearms at Bedside -- Firearms in the Home -- Firearms on Family Member or Visitor -- G -- Gastric Lavage -- Gastrointestinal Hemorrhage -- H -- Health Insurance Portability and Accountability Act -- Hearing Impairment -- Heart Failure, Daily Assessment -- Heat Therapy -- Hemodynamic Monitoring -- Home Care, Home Care Aide Needs -- Home Care, Initial Assessment -- Home Care, Interdisciplinary Communication in -- Home Care, Patient-Teaching Certification in -- Home Care Certification and Care Plan -- Home Care Discharge Summary -- Home Care Progress Notes -- Home Care Recertification -- Home Care Referral -- Home Care Telephone Orders -- Hyperglycemia -- Hyperosmolar Hyperglycemic Nonketotic Syndrome -- Hypertensive Crisis -- Hyperthermia-Hypothermia Blanket -- Hypoglycemia -- Hypotension -- Hypovolemia -- Hypoxemia -- IJK -- Illegal Alteration of a Medical Record -- Implanted Port, Accessing -- Implanted Port, Care of -- Implanted Port, Withdrawing Access -- Inappropriate Comment in the Medical Record -- Incident Report -- Increased Intracranial Pressure -- Infection Control -- Informed Consent, Inability to Give -- Informed Consent in Emergency Situation -- Informed Consent, Lack of Understanding of -- Informed Consent When Patient is a Minor -- Intake and Output -- Intestinal Obstruction -- Intra-Aortic Balloon Counterpulsation Care -- Intra-Aortic Balloon Insertion -- Intra-Aortic Balloon Removal -- Intracerebral Hemorrhage -- Intracranial Pressure Monitoring -- Intravenous Catheter Complication: Cannula Dislodgment -- Intravenous Catheter Complication: Phlebitis -- Intravenous Catheter Insertion -- Intravenous Catheter Removal -- Intravenous Site Care -- Intravenous Site Change -- Intravenous Site Infiltration -- Intravenous Therapy, Continuous -- L -- Language Difficulties -- Last Will and Testament, Patient Request for Witness of -- Late-Documentation Entry -- Latex Hypersensitivity -- Level of Consciousness, Changes in -- Lumbar Puncture -- M -- Mechanical Ventilation -- Medical Advice, Patient or Family Request for -- Medication Error -- Medications, Reconciling -- Misuse of Equipment -- Mixed Venous Oxygen Saturation Monitoring -- Moderate Sedation -- Multiple Trauma -- Myocardial Infarction, Acute -- N -- Nasogastric Tube Care -- Nasogastric Tube Insertion -- Nasogastric Tube Removal -- Newborn Identification -- Patient Nonadherence to Recommended Medical Care -- O -- Organ Donation -- Ostomy Care -- Overdose, Drug -- Oxygen Administration -- P -- Pacemaker, Care of Permanent -- Pacemaker, Care of Transcutaneous -- Pacemaker, Care of Transvenous -- Pacemaker, Initiation of Transcutaneous -- Pacemaker, Insertion of Permanent -- Pacemaker, Insertion of Transvenous -- Pacemaker Malfunction -- Pain Management -- Paracentesis -- Parenteral Nutrition Administration, Lipids -- Parenteral Nutrition Administration, Total -- Patient-Controlled Analgesia -- Patient Requesting Access to Medical Records -- Patient Self-Documentation of Care -- Patient Self-Glucose Testing -- Patient Teaching -- Patient Teaching, Patient's Refusal of -- Patient Threat of Self-Harm -- Patient Threat to Harm Another -- Patient Transfer to Long-Term Care Facility -- Patient Transfer to Specialty Unit -- Patient's Belongings, at Admission -- Peripherally Inserted Central Catheter Site Care -- Peritoneal Dialysis -- Peritoneal Dialysis, Continuous Ambulatory -- Peritoneal Lavage (Diagnostic Peritoneal Aspiration [DPA]) -- Peritonitis -- Pneumonia -- Pneumothorax -- Poisoning -- Postoperative Care -- Preoperative Care -- Pressure Ulcer (Pressure Injury) Assessment -- Pressure Ulcer (Pressure Injury) Care -- Psychosis, Acute -- Pulmonary Edema -- Pulmonary Embolism -- Pulse Oximetry -- Q -- Quality of Care, Family Questions About -- R -- Rape-Trauma Syndrome -- Refusal of Treatment -- Acute Kidney Injury -- Reports to Health Care Provider -- Respiratory Arrest -- Respiratory Distress -- Restraints -- S -- SBAR -- Seclusion -- Seizure Management -- Shock -- Sickle Cell Crisis -- Skin Care -- Skin Graft Care -- Smoking -- SOAP -- Spinal Cord Injury -- Splint Application -- Status Asthmaticus -- Status Epilepticus -- Stroke -- Surgical Amputation Care -- Subdural Hematoma -- Substance Abuse by Colleague, Suspicion of -- Substance Withdrawal -- Suicidal Intent -- Suicide Precautions -- Suicide Prevention Contract -- Surgical Incision Care -- Surgical Site Identification -- Suture Removal -- T -- Termination of Life Support -- Thoracentesis -- Thrombolytic Therapy -- Tracheostomy Care -- Tracheostomy Occlusion -- Tracheostomy Suctioning -- Tracheostomy Tube Replacement -- Tracheotomy -- Traction Care, Skeletal -- Traction Care, Skin -- Transcutaneous Electrical Nerve Stimulation -- Transfusion Reaction, Delayed -- Transient Ischemic Attack -- Tube Feeding (Enteral Feeding) -- Tuberculosis -- U -- Unresponsiveness by Patient -- Urinary Catheter Insertion, Indwelling -- V -- Vagal Maneuvers -- Ventricular Assist Device -- Violent Patient -- Vision Impairment -- Vital Signs, Frequent -- WXY -- Walker Use -- Wound Assessment -- Wound Care -- Wound Dehiscence -- Wound Evisceration -- Z -- Z-Track Injection -- Appendices -- Standardized Systems -- The Joint Commission Abbreviations to Avoid -- Institute for Safe Medication Practices (ISMP) Drug Sound-Alike/Look-Alike Names -- Common Charting Mistakes to Avoid -- Charting Checkup: When the Nurse is on Trial -- How to Protect Oneself -- The NANDA International Nursing Diagnoses.