Overview of Documentation -- 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 -- When your patient has hypertensive crisis -- When your patient has pneumonia -- When your patient has pneumothorax -- 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 -- When your patient has hypoglycemia -- When your patient has hyperglycemia -- When your patient has anaphylaxis -- When your patient has a transfusion reaction -- 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 -- 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 -- 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 himself -- 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 -- 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 -- 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 he 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.