Guide to Clinical Documentation

Name: Guide to Clinical Documentation
Price: 4.64 USD
Availability: InStock
ISBN: 9780803625839

ISBN-10: 0803625839

ISBN-13: 9780803625839

Edition: 2nd 2012 (Revised)

Authors: Debra D. Sullivan

List price: $54.95

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Description:

Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.This edition has been completely revised and upgraded with more in-depth coverage of documentation and its ramifications, more documentation samples to analyze and emulate, and even more learning tools. You'll also find access to our special version of Amazing Charts, online at DavisPlus. Amazing Charts is a fully functional, Windows-based, professional…

Book details

List price: $54.95
Edition: 2nd
Copyright year: 2012
Publisher: F. A. Davis Company
Publication date: 12/22/2011
Binding: Paperback
Pages: 320
Size: 8.00" wide x 11.00" long x 1.00" tall
Weight: 1.584
Language: English



Medicolegal Principles of Documentation


The Comprehensive History and Physical


Adult Preventative Care Visits


Pediatric Preventative Care Visits


SOAP Notes


Outpatient Charting and Communications


Admitting a Patient to the Hospital


Documenting Daily Rounds and Other Events


Discharging Patients from the Hospital


Prescription Writing and Electronic Prescribing


Appendices


Adult Prevention Care Timeline


A Guide to Sexual History


Taking Suggestions for Dictating Medical Records


ISMPï¿½ï¿½ï¿½s List of Error-Prone Abbreviations, Symbols, and Dose Designations


Worksheet Answer Key


Bibliography


Index