Document Smart. The A-to-Z Guide to Better Nursing Documentation

Feeling unsure about documenting patient care? Learn to document with skill and ease, with the freshly updated Document Smart, 4th Edition. This unique, easy-to-use resource is a must-have for every student and new nurse, offering more than 300 alpha-organized topics that demonstrate the latest nursing, medical and government best practices for documenting a wide variety of patient conditions and scenarios.

Whether you are assessing data, creating effective patient goals, choosing optimal interventions or evaluating treatment, this is your road map to documentation confidence and clarity.

Provide safe, high-quality patient care and documentation with this at-your-fingertips resource:

• NEW and updated content, including charting in electronic health/medical records, abbreviations to avoid, common charting mistakes and more
• NEW and updated resources – the CAGE questionnaire for alcohol abuse, the Tinetti Gait and Balance Scale, the Caregiver Role Strain Index, the Mini-Cog Assessment, the Depression Scale, Burn Assessment Scale and PAIN Scale
• NEW chapter on the S-B-A-R (Situation, Background, Assessment, Recommendation) technique
• NEW list of current nursing diagnoses from the North American Nursing Diagnostic Association (NANDA-I)
• 300 alphabetically arranged entries that address diseases, emergencies, procedures, legal and ethical issues and challenging nursing scenarios
• Quick-find explanations on numerous conditions, with the easily searchable index that offers the definition of each condition and explains nursing assessment and actions, followed by examples of nursing documentation
• Legal casebook sidebars that provide real-world examples of court cases and demonstrate how to document to protect yourself against lawsuits
• AccuChart boxes that offer guidelines and sample documentation, including admission assessments, patient medical records, flow sheets, progress notes and more
• Detailed nurses’ notes that depict real-life scenarios
• Guidance on safe medication administration from the Institute of Safe Medication Practices (ISMP)
• Quick-find alphabetized topics that include areas such as allergy testing, arrhythmias, initial assessment, bone marrow aspiration and biopsy, blood transfusion, burns assessment and care, cardiac monitoring, chest pain, death of patient, dementia, dyspnea, emergency treatment, end-of-life care, infection control, IV catheter care, language difficulties, lumbar puncture, mechanical ventilation, misuse of equipment, pneumothorax, pre- and post-operative care, parenteral nutrition, patient transfers, stroke, tracheostomy care, acute renal failure, restraints, seizure management, shock, violent patient, wound care, and more
• Your book purchase includes a complimentary download of the enhanced eBook for iOS™, Android™, PC and Mac. Take advantage of these practical features that will improve your eBook experience:
  
  • The ability to download the eBook on multiple devices at one time — providing a seamless reading experience online or offline
  • Easily convert to audiobook, powering your content with natural language text-to-speech
  • Powerful search tools and smart navigation cross-links that allow you to search within this book, or across your entire library of VitalSource eBooks

About the Clinical Editor

Teri Capriotti, DO, MSN, CRNP, RN, is Clinical Professor at the M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania.