Gift Guide

Mosby's Surefire Documentation: How, What, and When Nurses Need To Document / Edition 2

Paperback (Print)
Buy Used
Buy Used from
Used and New from Other Sellers
Used and New from Other Sellers
from $26.98
Usually ships in 1-2 business days
(Save 55%)
Other sellers (Paperback)
  • All (11) from $26.98   
  • New (2) from $57.87   
  • Used (9) from $26.98   

More About This Textbook


Mosby's Surefire Documentation, 2nd Edition offers clear, practical guidelines for how, what, and when to document for more than 100 of the most common and most important situations nurses face. Divided into 3 sections — Caring for Patients, Dealing with Challenging Patient Situations, and Handling Difficult Professional Problems — this essential resource details exactly what information to consider and document, to ensure quality patient care, continuity of care, and legal protection for the nurse and the institution where the nurse works.

• UNIQUE! Case histories that illustrate key legal points
• Tips to help nurses streamline documentation without sacrificing accuracy
• Guidance for documenting unusual or difficult developments or events
• Clear, concise explanations of complex legal terms and concepts
• Advice on how and why to document for a variety of documentation systems
• Charting Checklists identify essential points to record for a particular situation
• Legal Briefs explain legal terms, such as a living will, or give practical advice for avoiding legal pitfalls
• Case Law Close-Ups describe specific court cases, explain the court's ruling, and point out the nursing implications
• Tips and Advice help the nurse solve documentation problems, such as correcting a mistaken entry, and give advice on recording data in complex situations
• Did you know? sections present interesting, practical, or little-known points related to a specific topic

• Completely updated content throughout that reflects the latest information and guidelines affecting documentation, including HIPAA and JCAHO standards.
• Expanded coverage of electronic documentation and its implications for nurses.
• A wealth of new and expanded special features such as Charting Checklists, Legal Briefs, and Case Law Close-Ups that further illustrate important documentation and legal considerations

Mosby's Surefire Documentation, Second Edition, uses clear concise reading style to give specific, practical advice of how, what, and when to document over 100 of the most common and most important situations nurses face. Divided into 3 sections: Caring for Patients, Dealing with Special Situations, and Practicing Yourself Legally; each entry tells exactly what to consider and document, so that nurses can ensure quality patient care, continuity of care, and legal protection. The second edition will be thoroughly updated to reflect the latest HIPAA and JCAHO recommendations and standards as well as the most current legal tips and advice. A special emphasis will be placed on the evolving role and means of electronic documentation in the clinical setting.

Read More Show Less

Product Details

  • ISBN-13: 9780323034340
  • Publisher: Elsevier Health Sciences
  • Publication date: 1/31/2006
  • Edition description: New Edition
  • Edition number: 2
  • Pages: 432
  • Sales rank: 388,998
  • Product dimensions: 5.90 (w) x 8.90 (h) x 0.80 (d)

Table of 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 a new arrhythmia-NEW!
When your patient has hypertensive crisis- NEW!
When your patient has pneumonia
When your patient has pneumothorax- NEW!
When your patient has an asthma attack
When your patient has a pulmonary embolism
When your patient has pulmonary edema
When your patient has pulmonary tuberculosis
When your patient has severe pain
When your patient is confused
When your patient has a seizure
When your patient has a cerebrovascular accident
When your patient is unresponsive
When your patient aspirates a tube feeding
When your patient has GI hemorrhage- NEW!
When your patient has hypoglycemia
When your patient has hyperglycemia
When your patient has anaphylaxis
When your patient has a transfusion reaction- NEW!
When your patient has HIV infection
When your patient has a pressure ulcer
When your patient has an infected wound
When your patient has sepsis- NEW!
When your patient has an adverse drug reaction
When your patient has I.V. infiltration
When your patient has surgery
When your patient has wound dehiscence or evisceration- NEW!

Part 2: Dealing with Challenging Patient 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
When your patient becomes hostile
When your patient threatens to harm someone
When your patient must be restrained
When your patient is anxious
When your patient threatens suicide
When your patient accidentally injures herself
When your patient is caught smoking
When your patient has contraband
When your patient tampers with medical equipment
When your patient hides his drugs
When your patient removes her endotracheal tube
When your patient removes his chest tube
When your patient speaks a different language
When your patient has a hearing impairment
When your patient has a vision impairment
When your patient is obese- NEW!
When your patient can't give informed consent
When your patient doesn't understand the procedure he's about to undergo
When your patient's equipment fails
When your patient's belongings are missing
When your patient's family questions the quality of care
When you suspect that your patient has been abused
When your patient's visitors won't leave
When your patient is seriously ill- NEW!
When your patient asks you to witness her last will and testament
When a patient dies
When your patient donates an organ

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
How to document care given by unlicensed assistive personnel
When you're asked to countersign a colleague's notes
When you must work on an understaffed unit
When your patient or her family asks you for medical advice
When the physician and family decide to terminate the patient's life support
When the physician writes a “do not resuscitate” order
When you withhold a prescribed drug or other patient care
When someone asks to photograph or videotape your patient
When a member of the media asks for patient information
When your patient is transferred or discharged
How to make a late entry
How to use abbreviations safely
How to complete an incident report
How to avoid the pitfalls of computer documentation
How to protect your patient's privacy when faxing medical records
How to protect patient confidentiality when using the Internet

Read More Show Less

Customer Reviews

Be the first to write a review
( 0 )
Rating Distribution

5 Star


4 Star


3 Star


2 Star


1 Star


Your Rating:

Your Name: Create a Pen Name or

Barnes & Review Rules

Our reader reviews allow you to share your comments on titles you liked, or didn't, with others. By submitting an online review, you are representing to Barnes & that all information contained in your review is original and accurate in all respects, and that the submission of such content by you and the posting of such content by Barnes & does not and will not violate the rights of any third party. Please follow the rules below to help ensure that your review can be posted.

Reviews by Our Customers Under the Age of 13

We highly value and respect everyone's opinion concerning the titles we offer. However, we cannot allow persons under the age of 13 to have accounts at or to post customer reviews. Please see our Terms of Use for more details.

What to exclude from your review:

Please do not write about reviews, commentary, or information posted on the product page. If you see any errors in the information on the product page, please send us an email.

Reviews should not contain any of the following:

  • - HTML tags, profanity, obscenities, vulgarities, or comments that defame anyone
  • - Time-sensitive information such as tour dates, signings, lectures, etc.
  • - Single-word reviews. Other people will read your review to discover why you liked or didn't like the title. Be descriptive.
  • - Comments focusing on the author or that may ruin the ending for others
  • - Phone numbers, addresses, URLs
  • - Pricing and availability information or alternative ordering information
  • - Advertisements or commercial solicitation


  • - By submitting a review, you grant to Barnes & and its sublicensees the royalty-free, perpetual, irrevocable right and license to use the review in accordance with the Barnes & Terms of Use.
  • - Barnes & reserves the right not to post any review -- particularly those that do not follow the terms and conditions of these Rules. Barnes & also reserves the right to remove any review at any time without notice.
  • - See Terms of Use for other conditions and disclaimers.
Search for Products You'd Like to Recommend

Recommend other products that relate to your review. Just search for them below and share!

Create a Pen Name

Your Pen Name is your unique identity on It will appear on the reviews you write and other website activities. Your Pen Name cannot be edited, changed or deleted once submitted.

Your Pen Name can be any combination of alphanumeric characters (plus - and _), and must be at least two characters long.

Continue Anonymously
Sort by: Showing all of 4 Customer Reviews
  • Anonymous

    Posted September 25, 2006

    The Best Book on Documentation Out There

    Having just graduated as a nurse, I felt lost at sea whenever I charted at work. However, this book is fabulous and is helping me to be a better nurse and to chart in a way that provides me with legal protection. Here's how: by going over the most common diseases, what the symptoms and interventions are, and what patient education should include, I am learning how to take better care of my patient. When I take better care of my patient and with the help of the book, I document the legally important highlights of my care, my patients are cared for well and my documentation shows that. Perfect! The book also goes over difficult patient situations and professional problems that you surprisingly deal with alot, which is also extremely helpful. I can't recommend it enough, and I think that all new grads should have it.

    Was this review helpful? Yes  No   Report this review
  • Anonymous

    Posted March 12, 2009

    No text was provided for this review.

  • Anonymous

    Posted January 5, 2009

    No text was provided for this review.

  • Anonymous

    Posted January 19, 2009

    No text was provided for this review.

Sort by: Showing all of 4 Customer Reviews

If you find inappropriate content, please report it to Barnes & Noble
Why is this product inappropriate?
Comments (optional)