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Guide to Clinical Documentation Second Edition

4.4 4.4 out of 5 stars 172 ratings

There is a newer edition of this item:

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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. This edition has been completely revised and upgraded with more in-depth coverage of documentation and its ramifications, more documentation samples to analyze and emulate, and even more learning tools.

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Product details

  • ASIN ‏ : ‎ 0803625839
  • Publisher ‏ : ‎ F.A. Davis Company; Second edition (December 22, 2011)
  • Language ‏ : ‎ English
  • Paperback ‏ : ‎ 320 pages
  • ISBN-10 ‏ : ‎ 9780803625839
  • ISBN-13 ‏ : ‎ 978-0803625839
  • Item Weight ‏ : ‎ 1.6 pounds
  • Dimensions ‏ : ‎ 8 x 1 x 11 inches
  • Customer Reviews:
    4.4 4.4 out of 5 stars 172 ratings

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Debra D. Sullivan
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Customer reviews

4.4 out of 5 stars
172 global ratings

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Customers say

Customers find the book provides useful information and helpful worksheets for practicing documentation. They find the text easy to read, with simple language that conveys the material clearly. Many consider it a good resource and worth purchasing.

AI-generated from the text of customer reviews

33 customers mention "Information quality"32 positive1 negative

Customers find the book helpful for NP school. It provides useful worksheets to practice documentation. They find it informative and easy to read, with useful information needed for class completion. The book is considered a good resource.

"I love this book. It is an awesome guide. This is a "Must Buy" for healthcare professionals." Read more

"...My focus was learning the SOAP note, this book helped me understand how much more charting, other than SOAP's, must be completed for compliance..." Read more

"...It's a nice reference but if you have access to an online search engine (and I'm guessing you do!) you can find most of the information online...." Read more

"...I was praised by my Attending Physicians on the quality and expediency of my notes and I give all credit to this book...." Read more

5 customers mention "Language"5 positive0 negative

Customers find the book's language simple and adequate for conveying the material. They say it's a required text for their NP program.

"...The language used is adequate to convey the material for one to grasp easily. However the question and answer sections need to be rethought...." Read more

"Easy-to-read, informative text...." Read more

"The book is written simply, contains examples medical documentations...." Read more

"This was a required text for my NP program. I was impressed with the amount of information this author supplied in this book...." Read more

5 customers mention "Value for money"5 positive0 negative

Customers find the booklet useful and cost-effective. They say it's worth purchasing.

"This booklet is very useful and cost effective. I would recommend it for the price. I would make copies of the pages to take with you to clinic." Read more

"great price and it arrived very quickly" Read more

"It worths the spending to live a healthy life. I enjoy the text messaging part especially alerting you of critical messsages...." Read more

"definitely worth the purchase..." Read more

Top reviews from the United States

  • Reviewed in the United States on September 21, 2023
    I love this book. It is an awesome guide. This is a "Must Buy" for healthcare professionals.
  • Reviewed in the United States on January 18, 2014
    Right down to it charting instructions and guidance. Even discusses codes and other factors of charting I had not taken into such deep account before. My focus was learning the SOAP note, this book helped me understand how much more charting, other than SOAP's, must be completed for compliance standards. There were some areas I found elementary, simply because I already knew of them; however, other 'elementary areas' I had never considered before. I feel this book is for just about everyone who is learning to chart as a reimbursable provider. Every nickel counts. I believe this book teaches well, how to capture reimbursement by complete charting.
    7 people found this helpful
    Report
  • Reviewed in the United States on September 22, 2022
    Fast delivery, great condition.
  • Reviewed in the United States on November 9, 2013
    Informative book, however written a little poorly. A bit confusing layout and hierarchy of the material presented in each chapter.
    The language used is adequate to convey the material for one to grasp easily. However the question and answer sections need to be rethought. It does not sufficiently gauge what was learned in the chapter. It feels more like busy work. Nothing is explained clearly in the answers section. A little difficult to learn from mistakes without going back through the chapters and wasting time.

    Overall I would definitely recommend this text even if it not required by your program. It can be a great supplemant.
    5 people found this helpful
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  • Reviewed in the United States on November 14, 2014
    This book was okay. It was a bit dry and kind of boring, but I guess this isn't the most exciting topic. It's a nice reference but if you have access to an online search engine (and I'm guessing you do!) you can find most of the information online. Skip it unless you prefer an actual book.
    5 people found this helpful
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  • Reviewed in the United States on September 6, 2016
    As a 3rd year Medical Student, I purchased this book for use while in the Wards. I was given two weeks notice before heading to the Wards and practiced the material in the book at least once. The shorthand for both consultations and progress notes, as well as prescription shorthand, was very useful. I was praised by my Attending Physicians on the quality and expediency of my notes and I give all credit to this book. I highly recommend it to fellow Medical Students as well as anyone that comments on my clinical documents.
    8 people found this helpful
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  • Reviewed in the United States on September 7, 2012
    Easy-to-read, informative text. Enjoy that there are worksheets at the end of each chapter as well as other questions throughout the chapter to "test" your knowledge of material read. I believe this book will be a "keeper" as there is a lot of information to refer back to as I progress through my NP program.
    13 people found this helpful
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  • Reviewed in the United States on January 26, 2019
    Good book, intact package, fast shipping! Will recommend.