PART ONE: The Principles of Documentation · Documentation: An Overview · The Patient Record · Systems of Nursing Documentation · The Joint Commission on Accreditation of Healthcare Organizations Standards Related to Documentation · American Nurses' Association Standards of Care · PART TWO: Medical-Surgical Care Documentation Guidelines · Acquired Immune Deficiency Syndrome (AIDS) · Acute Myocardial Infarction · Alzheimer's Disease and Other Dementias · Amputation · Angina · Asthma · Brain Tumor · Cancer Care · Cardiac Surgical Care · Cataract Care · Cerebrovascular Accident · Chemotherapy · Chronic Obstructive Pulmonary Disease · Congestive Heart Failure · Decubitus Ulcer · Diabetes Mellitus · Dialysis · Diarrhea · Enteral Care · Fracture Care · Gastrostomy Tube · Hypertension · Immobile Patient · Impaction · Intestinal Obstruction · Intravenous Therapy Care · Mastectomy Care · Osteoarthritis · Ostomy · Pain Management · Peripheral Vascular Disease · Pneumonia · Sickle Cell Anemia · Surgical Care · Tracheostomy Care · Tuberculosis · Urinary Catheter Care · Wound Care · PART THREE: Specialty Care Documentation Guidelines · Hospice Care · Maternal-Child Care · APPENDIXES: A) NANDA-Approved Nursing Diagnoses B) Services Provided by Other Disciplines C) Abbreviations D) Resources · BIBLIOGRAPHY.