Guide to Clinical Documentation; 2nd edition
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Today?s clinical documentation requires the utmost skill and accuracy. The information you record can accurately convey your patients? problems or leave you open to malpractice claims. Your chart notes communicate the thoughts and actions your colleagues need to know to make informed decisions; provide crucial information for your patients? coders; and ensure full reimbursement from insurers. 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. Completely revised and upgraded, the 2nd Edition features 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 the EHR software system, Amazing Charts, online at DavisPlus. Amazing Charts is a fully functional, Windows-based, professional EHR software package used in doctors? offices everywhere.
By: Debra Sullivan
Publisher:
F.A. Davis Company
Print ISBN: 9780803625839, 0803625839
other ISBN: 9780803629974, 0803629974
Edition: 2nd
Copyright year: 2012
SKU: 9780803629974
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