Guide to Clinical Documentation

ISBN-10: 0803625839

ISBN-13: 9780803625839

Edition: 2nd 2012 (Revised)

Authors: Debra D. Sullivan

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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 EMR software package currently being used by more than 3,200 medical practices nationwide.
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Book details

List price: $54.95
Edition: 2nd
Copyright year: 2012
Publisher: F. A. Davis Company
Publication date: 12/22/2011
Binding: Paperback
Pages: 288
Size: 8.50" wide x 11.00" long x 0.75" tall
Weight: 1.870
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
ISMP���s List of Error-Prone Abbreviations, Symbols, and Dose Designations
Worksheet Answer Key
Bibliography
Index
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