NEW and updated content; including charting in electronic health/medical records; abbreviations to avoid; common charting mistakes and moreNEW 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 ScaleNEW chapter on the S-B-A-R (Situation; Background; Assessment; Recommendation) techniqueNEW 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 scenariosQuick-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 documentationLegal casebook sidebars that provide real-world examples of court cases and demonstrate how to document to protect yourself against lawsuitsAccuChart boxes that offer guidelines and sample documentation; including admission assessments; patient medical records; flow sheets; progress notes and moreDetailed nurses’ notes that depict real-life scenariosGuidance 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 moreYour 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.      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:

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