Guide to Clinical Documentation 2nd Edition – Digital Instant Dowload.
Product details:
- ISBN-10 : 9780803625839
- ISBN-13 : 978-0803625839
- Author: Debra D. Sullivan
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.
Table contents:
Chapter 1 Medicolegal Principles of Documentation
Chapter 2 The Comprehensive History and Physical Examination
Chapter 3 Adult Preventive Care Visits
Chapter 4 Pediatric Preventive Care Visits
Chapter 5 SOAP Notes
Chapter 6 Outpatient Charting and Communication
Chapter 7 Admitting a Patient to the Hospital
Chapter 8 Documenting Daily Rounds and Other Events
Chapter 9 Discharging Patients from the Hospital
Chapter 10 Prescription Writing and Electronic Prescribing
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