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This easy-to-read guide consists of different charting style examples (narrative, focused, SBAR, etc.), how to gather and chart clinical history.
References are provided by the American Nurse Association (ANA), Joint Commission (JC), and other credible sources.
This resource features:
Dos and don’ts of charting
Head-to-toe assessments
Detailed review of systems
More than 900 commonly used medical abbreviations from A-Z along with Joint Commission’s Do Not Use list
Nursing note examples, medical illustrations, personal stories and much more
