This thoroughly updated edition now includes the benefits and cautions of computerized charting, expanded home health charting, a completed sample OASIS-B form, a completed sample Minimum Data Set 2.0 form, most recent JCAHO Nursing Care and Documentation Standards, and a helpful glossary. Contents include contributors; foreword; nursing documentation and the medical record; legal and ethical implications of documentation; quality management and reimbursement; documentation systems; documentation in acute care, long-term care, and home care; documentation of the nursing process and everyday events; legally perilous charting practices; malpractice lawsuits; appendices, including 1998 NANDA taxonomy, ANA standards of nursing practice, 1998 JCAHO nursing care and documentation standards, documentation guidelines for common nursing diagnoses, nursing organizations, and commonly accepted abbreviations and symbols; glossary; and index.

A Brandon-Hill Recommended Title.