(eBook PDF) Guide to Clinical Documentation 3rd Edition – Digital Ebook – Instant Delivery Download
Product details:
- ISBN-10 : 0803666624
- ISBN-13 : 978-0803666627
- Author: Debra D. Sullivan
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.
Table contents:
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. Documenting Prenatal Care and Visits and Newborn Physical Examination
Perinatal Events
5. Pediatric Preventive Care Visits
6. Adult Preventive Care Visits
7. Older Adult Preventative Care 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
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