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Product Description
- Reviews the terminology for written
communications with physicians and staff.
- Describe the types of documentation,
including SOAP notes and DART charts. - Details the documentation of history taking,
including medical, social, and family
history, physical assessments, and systems. - Covers the documentation of nursing
skills and procedures as well as medication
administration. - Addresses the documentation required in
specialized fields such as OB/GYN, pediatrics,
psychiatric, and outpatient nursing. - Includes how-tos for template, electronic,
and other forms of charting.
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