Guide to Clinical Documentation
Product Description
Guide to Clinical Documentation
- Understand the when, why, and how! Here's your guide to developing the skills you need to master the increasing complex challenges of documenting patient care. Step by step, a straightforward 'how-to' approach teaches you how to write SOAP notes, document patient care in office and hospital settings, and write prescriptions. You'll find a wealth of examples, exercises, and instructions that make every point clear and easy to understand.
- 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 chapter
- Coverage of -problem-oriented medical records, patients with multiple complaints or multiple conditions
- Hands-on, problem-based exercises
- Worksheets at the end of each chapter
- Examples of "good" and "bad" documentation for evaluation
- Real-life case studies that illustrate the potential consequences of poor or inaccurate documentation.
- Explanations of use and terminology of ICD-10-CM codes in billing
- Boxes highlighting medicolegal considerations.
Technical Specifications
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