Guide to Clinical Documentation

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.

<ul><br /> <li style="margin-left: 0.25in;"><span>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</span></li><br /> <li style="margin-left: 0.25in;"><span>Coverage of -problem-oriented medical records, patients with multiple complaints or multiple conditions</span></li><br /> <li style="margin-left: 0.25in;"><span>Hands-on, problem-based exercises</span></li><br /> <li style="margin-left: 0.25in;"><span>Worksheets at the end of each chapter</span></li><br /> <li style="margin-left: 0.25in;"><span>Examples of "good" and "bad" documentation for evaluation</span></li><br /> <li style="margin-left: 0.25in;"><span>Real-life case studies that illustrate the potential consequences of poor or inaccurate documentation.</span></li><br /> <li style="margin-left: 0.25in;"><span>Explanations of use and terminology of ICD-10-CM codes in billing</span></li><br /> <li style="margin-left: 0.25in;"><span></span>Boxes highlighting medicolegal considerations.</li><br /></ul>