Guide To Clinical Documentation

Author: Debra D Sullivan
Publisher: F.A. Davis
ISBN: 0803669992
Size: 45.12 MB
Format: PDF, ePub
View: 5242
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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.

Guide To Clinical Documentation

Author: Debra Sullivan
Publisher: F.A. Davis
ISBN: 0803629974
Size: 30.70 MB
Format: PDF, Docs
View: 2034
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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.

Guide To Clinical Documentation

Author: Debra D. Sullivan
Publisher:
ISBN: 9780803666627
Size: 59.64 MB
Format: PDF, ePub, Docs
View: 1162
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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. See what practitioners and students are saying online... Definitely worth the purchase. "This is a guide which will stay with you during your whole nursing program...so do not rent you must buy it and think of it as a documentation bible!"--Barbie Great resource for NP/PA school. "Purchased this for my NP program. The book made writing SOAP notes and H&Ps very simple! Would recommend as a great resource"--Dr. Jon Love this! "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. ... this book helped me understand how much more charting, other than SOAP's, must be completed for compliance standards. I feel this book is for just about everyone who is learning to chart as a reimbursable provider. --D. Conley

Guide To Clinical Documentation

Author: Debra D Sullivan
Publisher: F.A. Davis
ISBN: 0803669992
Size: 34.30 MB
Format: PDF, ePub, Mobi
View: 7697
Download
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.

Documentation For Rehabilitation

Author: Lori Quinn
Publisher: Elsevier Health Sciences
ISBN: 0323312330
Size: 16.70 MB
Format: PDF
View: 4691
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Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you've learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning. A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model - the one adopted by the APTA. Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings. Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies - especially important when insurance companies require evidence of functional progress in order to provide reimbursement. Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts. NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries. UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding. EXPANDED number of case examples covers an even broader range of clinical practice areas.

The Counselor S Steps For Progress Notes

Author: Rhonda Sutton
Publisher: Createspace Independent Publishing Platform
ISBN: 9781514643587
Size: 12.68 MB
Format: PDF, Docs
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Dr. Rhonda Sutton's second edition of the straightforward guide to progress notes includes additional examples, information, documentation, and clinical language that expands on the utility and readability of the first book. Additional case studies provide examples of how to use the STEPs to format notes. New chapters include information on clinical language and documentation. This book covers everything about progress notes, from how to write them, to how to store them, and even what to do when someone requests to them. In addition, clinical terms and abbreviations are included as well as suggestions for other clinical documentation such as termination letters, privacy statements, and professional disclosure statements. Suited for all types of mental health clinicians, this book will help therapists improve upon their progress notes and other forms of clinical documentation.

The Physician Advisor S Guide To Clinical Documentation Improvement

Author: Trey La Charite
Publisher: Hcpro, a Division of Blr
ISBN: 9781615693474
Size: 65.88 MB
Format: PDF, Mobi
View: 954
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The Physician Advisor's Guide to Clinical Documentation Improvement Physician advisors are not just needed for case management anymore. ICD-10-CM/PCS and the changing landscape of healthcare reimbursement make their input invaluable in the realm of CDI and coding, too. This book will help your physician advisors quickly understand the vital role they play and how they can not only help improve healthcare reimbursement, but also reduce claims denials and improve the quality of care overall. This book will: * Provide job descriptions and sample roles and responsibilities for CDI physician advisors * Outline the importance of CDI efforts in specific relation to the needs and expectations of physicians * Highlight documentation improvement focus areas by Major Diagnostic Category * Review government initiatives and claims denial patterns, providing physician advisors concrete tools to sway physician documentation

Docunotes

Author: Cherie Rebar
Publisher: F.A. Davis
ISBN: 0803623364
Size: 27.44 MB
Format: PDF
View: 7010
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The perfect guide to charting! The popular Davis’s Notes format makes sure that you always have the information you need close at hand to ensure your documentation is not only complete and thorough, but also meets the highest ethical and legal standards. You’ll even find coverage of the nuances that are relevant to various specialties, including pediatric, OB/GYN, psychiatric, and outpatient nursing.

Documentation For Physician Assistants

Author: Debra D. Sullivan
Publisher: F A Davis Company
ISBN: 9780803611412
Size: 33.39 MB
Format: PDF, Kindle
View: 1242
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"GREAT! Specifically addresed PA concerns with appropriate information. Enjoyed the 'Practice' format and especially the pearls." -- Peggy D. McMillen, MPAS, PAC, PA Studies, East Carolina University, Greenville, North Carolina Numerous examples with hands-on, problem-based exercises