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Guide to Clinical Documentation / Edition 2
     

Guide to Clinical Documentation / Edition 2

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by Debra D. Sullivan
 

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ISBN-10: 0803625839

ISBN-13: 9780803625839

Pub. Date: 12/22/2011

Publisher: F. A. Davis Company

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

Overview

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.

Product Details

ISBN-13:
9780803625839
Publisher:
F. A. Davis Company
Publication date:
12/22/2011
Edition description:
New Edition
Pages:
320
Sales rank:
62,324
Product dimensions:
8.40(w) x 10.70(h) x 0.80(d)

Related Subjects

Table of Contents

  1. Medicolegal Principles of Documentation
  2. The Comprehensive History and Physical
  3. Adult Preventative Care Visits
  4. Pediatric Preventative Care Visits
  5. SOAP Notes
  6. Outpatient Charting and Communications
  7. Admitting a Patient to the Hospital
  8. Documenting Daily Rounds and Other Events
  9. Discharging Patients from the Hospital
  10. 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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Guide to Clinical Documentation 5 out of 5 based on 0 ratings. 1 reviews.
huajvaj More than 1 year ago
EXcellent product and very useful