Surefire documentation : how, what, and when nurses need to document.

Contents;

Part 1: Caring for patients
When you perform your initial patient assessment
When your patient loses a peripheral pulse
When your patient has chest pain
When your patient has a myocardial infarction
When your patient has heart failure
When your patient is in shock
When your patient has cardiopulmonary arrest
When your patient has pneumonia
When your patient has an asthma attack
When your patient has pulmonary embolism
When your patient has pulmonary edema
etc.

Part 2: Dealing with challenging situations
When your patient documents her own care
When your patient asks to see his medical record
When your patient's medical record isn't available
When your patient withholds his medical history
When your patient refuses treatment
When your patient is noncompliant
When your patient is in police custody
When your patient leaves against medical advice
When your patient threatens to sue
When your patient makes a sexual advance
etc.

Part 3: Handling difficult professional problems
When a physician or colleague illegally alters the medical record
When a colleague criticizes your care in the medical record
When you find an inappropriate comment in the medical record
When a physician asks to remove a medical record from the facility
How to handle a physician's questionable order
When you take a telephone or verbal order
When a physician's order is illegible
When a colleague asks you to document her care
When a coworker gives your patient drugs in your absence
When you suspect that a colleague is negligent
etc.

Index : p. 318-325.