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Author: Lippincott Williams & Wilkins
Publisher: Lippincott Williams & Wilkins
ISBN: 9781582555560
Category : Medical
Languages : en
Pages : 454
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Book Description
Thoroughly updated for its Second Edition, this comprehensive reference provides clear, practical guidelines on documenting patient care in all nursing practice settings, the leading clinical specialties, and current documentation systems. This edition features greatly expanded coverage of computerized charting and electronic medical records (EMRs), complete guidelines for documenting JCAHO safety goals, and new information on charting pain management. Hundreds of filled-in sample forms show specific content and wording. Icons highlight tips and timesavers, critical case law and legal safeguards, and advice for special situations. Appendices include NANDA taxonomy, JCAHO documentation standards, and documenting outcomes and interventions for key nursing diagnoses.
Author: Lippincott Williams & Wilkins
Publisher: Lippincott Williams & Wilkins
ISBN: 9781582555560
Category : Medical
Languages : en
Pages : 454
Get Book Here
Book Description
Thoroughly updated for its Second Edition, this comprehensive reference provides clear, practical guidelines on documenting patient care in all nursing practice settings, the leading clinical specialties, and current documentation systems. This edition features greatly expanded coverage of computerized charting and electronic medical records (EMRs), complete guidelines for documenting JCAHO safety goals, and new information on charting pain management. Hundreds of filled-in sample forms show specific content and wording. Icons highlight tips and timesavers, critical case law and legal safeguards, and advice for special situations. Appendices include NANDA taxonomy, JCAHO documentation standards, and documenting outcomes and interventions for key nursing diagnoses.
Author: Debra Sullivan
Publisher: F.A. Davis
ISBN: 0803629974
Category : Medical
Languages : en
Pages : 301
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Book Description
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.
Author: LIPPINCOTT
Publisher:
ISBN: 9781609136185
Category : Medical
Languages : en
Pages : 448
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Book Description
Everything the nurse needs to know to make documenting patient care better, faster, safer, comprehensive, yet concise. Clear, practical documentation guidelines for all current documentation systems, including electronic medical records EMRs and all practice settings. Hundreds of filled-in sample forms and examples show specific content and wording, legal and ethical dos and donts.
Author: John Rakos
Publisher: John Wiley & Sons
ISBN: 1119120241
Category : Technology & Engineering
Languages : en
Pages : 275
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Book Description
Project Management The one-stop resource for project management documentation and templates for all projects The success of any project is crucially dependent on the documents produced for it. The Practical Guide to Project Management Documentation provides a complete and reliable source of explanations and examples for every possible project-related document-from the proposal, business case, and project plan, to the status report and final post-project review. The Practical Guide to Project Management Documentation is packed with material that slashes the time and effort expended on producing new documents from scratch. Following the processes in the Project Management Institute's PMBOK® Guide, this one-stop, full-service book also offers tips and techniques for working with documents in each project process. Documentation for several project/client scenarios is addressed, including internal and externally contracted projects. A single project-the construction of a water theme park-is used as the case study for all the document examples. An included CD-ROM provides all the documents from the book as Microsoft Word(r) files. Readers can use these as a framework to develop their own project documents. The Practical Guide to Project Management Documentation is an unmatched reference for the numerous documents essential to project managers in all industries. (PMBOK is a registered mark of the Project Management Institute, Inc.)
Author: Sherry Borcherding
Publisher: SLACK Incorporated
ISBN: 9781556427794
Category : Medical
Languages : en
Pages : 244
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Book Description
Written specifically for occupational therapy assistants, The OTA's Guide to Writing SOAP Notes, Second Edition is updated to include new features and information. This valuable text contains the step-by-step instruction needed to learn the documentation required for reimbursement in occupational therapy. With the current changes in healthcare, proper documentation of client care is essential to meeting legal and ethical standards for reimbursement of services. Written in an easy-to-read format, this new edition by Sherry Borcherding and Marie J. Morreale will continue to aid occupational therapy assistants in learning to write SOAP notes that will be reimbursable under Medicare Part B and managed care for different areas of clinical practice. New Features in the Second Edition: - Incorporated throughout the text is the Occupational Therapy Practice Framework, along with updated AOTA documents - More examples of pediatrics, hand therapy, and mental health - Updated and additional worksheets - Review of grammar/documentation mistakes - Worksheets for deciphering physician orders, as well as expanded worksheets for medical abbreviations - Updated information on billing codes, HIPAA, management of health information, medical records, and electronic documentation - Expanded information on the OT process for the OTA to fully understand documentation and the OTA's role in all stages of treatment, including referral, evaluation, intervention plan, and discharge - Documentation of physical agent modalities With reorganized and shorter chapters, The OTA's Guide to Writing SOAP Notes, Second Edition is the essential text to providing instruction in writing SOAP notes specifically aimed at the OTA practitioner and student. This exceptional edition offers both the necessary instruction and multiple opportunities to practice, as skills are built on each other in a logical manner. Templates are provided for beginning students to use in formatting SOAP notes, and the task of documentation is broken down into small units to make learning easier. A detachable summary sheet is included that can be pulled out and carried to clinical sites as a reminder of the necessary contents for a SOAP note. Updated information, expanded discussions, and reorganized learning tools make The OTA's Guide to Writing SOAP Notes, Second Edition a must-have for all occupational therapy assistant students! This text is the essential resource needed to master professional documentation skills in today's healthcare environment.
Author: AAPC
Publisher: AAPC
ISBN: 1626889791
Category : Medical
Languages : en
Pages : 13
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Book Description
It's not the quantity of clinical documentation that matters—it's the quality. Is your clinical documentation improvement (CDI) program identifying your outliers? Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Are you clear on how to fix your coding and documentation shortfalls? Providing the most complete and accurate coding of diagnoses and site-specific procedures will vastly improve your practice’s bottom line. Get the help you need with the Clinical Documentation Reference Guide. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complications and comorbidities, and CDI for EMRs. Learn the all-important steps to ensure your records capture what your physicians perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the practical and effective guidance in AAPC’s Clinical Documentation Reference Guide to triumph over your toughest documentation challenges. Prevent documentation deficiencies and keep your claims on track for optimal reimbursement: Understand the legal aspects of documentation Anticipate and avoid documentation trouble spots Keep compliance issues at bay Learn proactive measures to eliminate documentation problems Work the coding mantra—specificity, specificity, specificity Avoid common documentation errors identified by CERT and RACs Know the facts about EMR templates—and the pitfalls of auto-populate features Master documentation in the EMR with guidelines and tips Conquer CDI time-based coding for E/M The Clinical Documentation Reference Guide is approved for use during the CDEO® certification exam.
Author: Andreas Rüping
Publisher: John Wiley & Sons
ISBN: 0470856246
Category : Computers
Languages : en
Pages : 244
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Book Description
Software documentation forms the basis for all communication relating to a software project. To be truly effective and usable, it should be based on what needs to be known. Agile Documentation provides sound advice on how to produce lean and lightweight software documentation. It will be welcomed by all project team members who want to cut out the fat from this time consuming task. Guidance given in pattern form, easily digested and cross-referenced, provides solutions to common problems. Straightforward advice will help you to judge: What details should be left in and what left out When communication face-to-face would be better than paper or online How to adapt the documentation process to the requirements of individual projects and build in change How to organise documents and make them easily accessible When to use diagrams rather than text How to choose the right tools and techniques How documentation impacts the customer Better than offering pat answers or prescriptions, this book will help you to understand the elements and processes that can be found repeatedly in good project documentation and which can be shaped and designed to address your individual circumstance. The author uses real-world examples and utilises agile principles to provide an accessible, practical pattern-based guide which shows how to produce necessary and high quality documentation.
Author: Donald E. Wiger
Publisher: John Wiley & Sons
ISBN: 0470527781
Category : Psychology
Languages : en
Pages : 338
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Book Description
All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.
Author:
Publisher: Springhouse Corporation
ISBN:
Category : Medical
Languages : en
Pages : 516
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Book Description
Chart Smart: the A-to-Z Guide to Better Nursing Documentation tells nurses exactly what to document in virtually every type of situation they may encounter on the job, no matter where they practice--hospital, medical office, outpatient, rehabilitation facility, long-term care facility, or home. This portable handbook has nearly 300 entries that cover documentation required for common diseases, major emergencies, complex procedures, and difficult situations involving patients, families, other health care team members, and supervisors. In addition to patient care, this book also covers documenta
Author: Anne Gentle
Publisher: Lulu.com
ISBN: 1387081322
Category : Computers
Languages : en
Pages : 118
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Book Description
Looking for a way to invigorate your technical writing team and grow that expertise to include developers, designers, and writers of all backgrounds? When you treat docs like code, you multiply everyone's efforts and streamline processes through collaboration, automation, and innovation. Second edition now available with updates and more information about version control for documents and continuous publishing.
