Guide to Clinical Documentation
Edition: 2nd 2012 (Revised)
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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.
Copyright year: 2012
Publisher: F. A. Davis Company
Publication date: 12/22/2011
Size: 8.50" wide x 11.00" long x 0.75" tall
|Medicolegal Principles of Documentation|
|The Comprehensive History and Physical|
|Adult Preventative Care Visits|
|Pediatric Preventative Care Visits|
|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|
|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|