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Contributors and Consultants | |
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Foreword | |
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Overview of Documentation | |
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Caring for Patients | |
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When you perform your initial patient assessment | |
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When your patient loses a peripheral pulse | |
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When your patient has chest pain | |
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When your patient has a myocardial infarction | |
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When your patient has heart failure | |
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When your patient is in shock | |
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When your patient has cardiopulmonary arrest | |
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When your patient has a new arrhythmia | |
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When your patient has hypertensive crisis | |
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When your patient has pneumonia | |
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When your patient has pneumothorax | |
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When your patient has an asthma attack | |
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When your patient has a pulmonary embolism | |
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When your patient has pulmonary edema | |
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When your patient has pulmonary tuberculosis | |
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When your patient has severe pain | |
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When your patient is confused | |
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When your patient has a seizure | |
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When your patient has a cerebrovascular accident | |
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When your patient is unresponsive | |
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When your patient aspirates a tube feeding | |
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When your patient has GI hemorrhage | |
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When your patient has hypoglycemia | |
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When your patient has hyperglycemia | |
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When your patient has anaphylaxis | |
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When your patient has a transfusion reaction | |
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When your patient has HIV infection | |
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When your patient has a pressure ulcer | |
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When your patient has an infected wound | |
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When your patient has sepsis | |
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When your patient has an adverse drug reaction | |
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When your patient has I.V. infiltration | |
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When your patient has surgery | |
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When your patient has wound dehiscence or evisceration | |
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Dealing with Challenging Patient Situations | |
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When your patient documents her own care | |
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When your patient asks to see his medical record | |
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When your patient's medical record isn't available | |
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When your patient withholds his medical history | |
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When your patient refuses treatment | |
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When your patient is noncompliant | |
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When your patient is in police custody | |
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When your patient leaves against medical advice | |
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When your patient threatens to sue | |
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When your patient makes a sexual advance | |
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When your patient becomes hostile | |
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When your patient threatens to harm someone | |
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When your patient must be restrained | |
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When your patient is anxious | |
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When your patient threatens suicide | |
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When your patient accidentally injures himself | |
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When your patient is caught smoking | |
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When your patient has contraband | |
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When your patient tampers with medical equipment | |
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When your patient hides his drugs | |
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When your patient removes her endotracheal tube | |
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When your patient removes his chest tube | |
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When your patient speaks a different language | |
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When your patient has a hearing impairment | |
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When your patient has a vision impairment | |
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When your patient is obese | |
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When your patient can't give informed consent | |
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When your patient doesn't understand the procedure he's about to undergo | |
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When your patient's equipment fails | |
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When your patient's belongings are missing | |
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When your patient's family questions the quality of care | |
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When you suspect that your patient has been abused | |
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When your patient's visitors won't leave | |
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When your patient is seriously ill | |
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When your patient asks you to witness her last will and testament | |
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When a patient dies | |
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When your patient donates an organ | |
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Handling Difficult Professional Problems | |
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When a physician or colleague illegally alters the medical record | |
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When a colleague criticizes your care in the medical record | |
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When you find an inappropriate comment in the medical record | |
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When a physician asks to remove a medical record from the facility | |
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How to handle a physician's questionable order | |
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When you take a telephone or verbal order | |
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When a physician's order is illegible | |
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When a colleague asks you to document her care | |
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When a coworker gives your patient drugs in your absence | |
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When you suspect that a colleague is negligent | |
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How to document care given by unlicensed assistive personnel | |
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When you're asked to countersign a colleague's notes | |
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When you must work on an understaffed unit | |
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When your patient or her family asks you for medical advice | |
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When the physician and family decide to terminate the patient's life support | |
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When the physician writes a "do not resuscitate" order | |
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When you withhold a prescribed drug or other patient care | |
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When someone asks to photograph or videotape your patient | |
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When a member of the media asks for patient information | |
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When your patient is transferred or discharged | |
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How to make a late entry | |
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How to use abbreviations safely | |
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How to complete an incident report | |
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How to avoid the pitfalls of computer documentation | |
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How to protect your patient's privacy when faxing medical records | |
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How to protect patient confidentiality when using the Internet | |
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Index | |