Guide to Clinical Documentation

Product Description

• 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.

Features

• 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.

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