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Guide to Clinical Documentation

Guide to Clinical Documentation

9780803666627
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Description
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.
Product Details
Eurospan
67993
9780803666627
9780803666627

Data sheet

Publication date
2018
Issue number
3
Cover
paperback
Pages count
368
Dimensions (mm)
152.00 x 229.00
  • I. Foundations of Documentation 1. Medicolegal Principles of Documentation 2. The Comprehensive History and Physical Examination 3. SOAP Notes II. Documentation Related to Outpatient Care 4. Prenatal Care Visits and Newborn Physical Examination 5. Pediatric Preventive Care Visits 6. Adult Preventive Care Visits 7. Older Adult Visits 8. Outpatient Charting and Communication 9. Prescription Writing and Electronic Prescribing III. Documentation Related to Inpatient Care 10. Admitting a Patient to the Hospital 11. Documenting Inpatient Care 12. Discharging Patients from the Hospital Appendices A. Document Library B. A Guide to Sexual History Taking C. ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations Bibliography
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