| Contributors and Consultants | p. vii |
| Foreword | p. ix |
| Overview of Documentation | p. 1 |
| Caring for Patients | p. 11 |
| When you perform your initial patient assessment | p. 15 |
| When your patient loses a peripheral pulse | p. 23 |
| When your patient has chest pain | p. 28 |
| When your patient has a myocardial infarction | p. 34 |
| When your patient has heart failure | p. 39 |
| When your patient is in shock | p. 46 |
| When your patient has cardiopulmonary arrest | p. 52 |
| When your patient has a new arrhythmia | p. 57 |
| When your patient has hypertensive crisis | p. 63 |
| When your patient has pneumonia | p. 68 |
| When your patient has pneumothorax | p. 76 |
| When your patient has an asthma attack | p. 81 |
| When your patient has a pulmonary embolism | p. 86 |
| When your patient has pulmonary edema | p. 91 |
| When your patient has pulmonary tuberculosis | p. 96 |
| When your patient has severe pain | p. 102 |
| When your patient is confused | p. 109 |
| When your patient has a seizure | p. 114 |
| When your patient has a cerebrovascular accident | p. 120 |
| When your patient is unresponsive | p. 125 |
| When your patient aspirates a tube feeding | p. 130 |
| When your patient has GI hemorrhage | p. 133 |
| When your patient has hypoglycemia | p. 140 |
| When your patient has hyperglycemia | p. 143 |
| When your patient has anaphylaxis | p. 147 |
| When your patient has a transfusion reaction | p. 150 |
| When your patient has HIV infection | p. 154 |
| When your patient has a pressure ulcer | p. 159 |
| When your patient has an infected wound | p. 166 |
| When your patient has sepsis | p. 173 |
| When your patient has an adverse drug reaction | p. 177 |
| When your patient has I.V. infiltration | p. 181 |
| When your patient has surgery | p. 184 |
| When your patient has wound dehiscence or evisceration | p. 193 |
| Dealing with Challenging Patient Situations | p. 199 |
| When your patient documents her own care | p. 202 |
| When your patient asks to see his medical record | p. 204 |
| When your patient's medical record isn't available | p. 208 |
| When your patient withholds his medical history | p. 212 |
| When your patient refuses treatment | p. 215 |
| When your patient is noncompliant | p. 218 |
| When your patient is in police custody | p. 220 |
| When your patient leaves against medical advice | p. 225 |
| When your patient threatens to sue | p. 228 |
| When your patient makes a sexual advance | p. 233 |
| When your patient becomes hostile | p. 236 |
| When your patient threatens to harm someone | p. 239 |
| When your patient must be restrained | p. 244 |
| When your patient is anxious | p. 251 |
| When your patient threatens suicide | p. 254 |
| When your patient accidentally injures himself | p. 260 |
| When your patient is caught smoking | p. 266 |
| When your patient has contraband | p. 269 |
| When your patient tampers with medical equipment | p. 272 |
| When your patient hides his drugs | p. 275 |
| When your patient removes her endotracheal tube | p. 278 |
| When your patient removes his chest tube | p. 280 |
| When your patient speaks a different language | p. 283 |
| When your patient has a hearing impairment | p. 285 |
| When your patient has a vision impairment | p. 288 |
| When your patient is obese | p. 291 |
| When your patient can't give informed consent | p. 294 |
| When your patient doesn't understand the procedure he's about to undergo | p. 299 |
| When your patient's equipment fails | p. 301 |
| When your patient's belongings are missing | p. 304 |
| When your patient's family questions the quality of care | p. 306 |
| When you suspect that your patient has been abused | p. 308 |
| When your patient's visitors won't leave | p. 311 |
| When your patient is seriously ill | p. 313 |
| When your patient asks you to witness her last will and testament | p. 316 |
| When a patient dies | p. 320 |
| When your patient donates an organ | p. 323 |
| Handling Difficult Professional Problems | p. 329 |
| When a physician or colleague illegally alters the medical record | p. 332 |
| When a colleague criticizes your care in the medical record | p. 335 |
| When you find an inappropriate comment in the medical record | p. 337 |
| When a physician asks to remove a medical record from the facility | p. 338 |
| How to handle a physician's questionable order | p. 342 |
| When you take a telephone or verbal order | p. 344 |
| When a physician's order is illegible | p. 347 |
| When a colleague asks you to document her care | p. 349 |
| When a coworker gives your patient drugs in your absence | p. 351 |
| When you suspect that a colleague is negligent | p. 352 |
| How to document care given by unlicensed assistive personnel | p. 353 |
| When you're asked to countersign a colleague's notes | p. 356 |
| When you must work on an understaffed unit | p. 358 |
| When your patient or her family asks you for medical advice | p. 360 |
| When the physician and family decide to terminate the patient's life support | p. 363 |
| When the physician writes a "do not resuscitate" order | p. 366 |
| When you withhold a prescribed drug or other patient care | p. 369 |
| When someone asks to photograph or videotape your patient | p. 370 |
| When a member of the media asks for patient information | p. 372 |
| When your patient is transferred or discharged | p. 374 |
| How to make a late entry | p. 377 |
| How to use abbreviations safely | p. 381 |
| How to complete an incident report | p. 383 |
| How to avoid the pitfalls of computer documentation | p. 386 |
| How to protect your patient's privacy when faxing medical records | p. 389 |
| How to protect patient confidentiality when using the Internet | p. 392 |
| Index | p. 395 |
| Table of Contents provided by Ingram. All Rights Reserved. |
