This portable handbook shows nurses in all practice settings exactly what to document in any situation. Nearly 300 alphabetically organized entries cover diseases, emergencies, procedures, legal and ethical problems, and difficult situations involving patients, families, and other health care professionals. Legal Casebooks provide examples of legal implications of documentation. AccuChart sample forms show how to accurately complete various forms.

Thoroughly updated to reflect current practice, this Second Edition provides information on the electronic health record. New entries cover situations such as surgical site verification, patient glucose self-testing, cultural needs identification, HIPAA, and reporting critical test values. A new appendix covers prohibited abbreviations.