Guide To Clinical Documentation

Item Information
Item#: 9780803666627
Edition 03
Author Sullivan, Debra D
Cover Paperback
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Learning objectives in each chapter to help you recognize important concepts at the beginning of the chapter, and reinforce what is summarized at the end of each chapterCoverage of -problem-oriented medical records, patients with multiple complaints or multiple conditionsHands-on, problem-based exercisesWorksheets at the end of each chapterExamples of \"good\" and \"bad\" documentation for evaluationReal-life case studies that illustrate the potential consequences of poor or inaccurate documentation.Explanations of use and terminology of ICD-10-CM codes in billingBoxes highlighting medicolegal considerations.

Table of Contents
I. Foundations of Documentation<
/>1. Medicolegal Principles of Documentation<
/>2. The Comprehensive History and Physical Examination<
/>3. SOAP Notes<
/><
/>II. Documentation Related to Outpatient Care<
/>4. Documenting Prenatal Care and Visits and Newborn Physical Examination<
/>Perinatal Events<
/>5. Pediatric Preventive Care Visits<
/>6. Adult Preventive Care Visits<
/>7. Older Adult Preventative Care Visits<
/>8. Outpatient Charting and Communication<
/>9. Prescription Writing and Electronic Prescribing<
/><
/>III. Documentation Related to Inpatient Care<
/>10. Admitting a Patient to the Hospital<
/>11. Documenting Inpatient Care<
/>12. Discharging Patients from the Hospital<
/><
/>Appendices<
/>A. Document Li
ary<
/>B. A Guide to Sexual History Taking<
/>C. ISMP&s List of Error-Prone Ab
eviations, Symbols, and Dose Designations<
/>Bibliography<
/>Index