Documentation for Medical Records

Documentation for Medical Records PDF Author: Barbara Odom-Wesley
Publisher:
ISBN: 9781584261834
Category : Medical informatics
Languages : en
Pages : 538

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Documentation for Medical Records

Documentation for Medical Records PDF Author: Barbara Odom-Wesley
Publisher:
ISBN: 9781584261834
Category : Medical informatics
Languages : en
Pages : 538

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Book Description


Documentation for Health Records

Documentation for Health Records PDF Author: Cheryl Gregg Fahrenholz
Publisher:
ISBN: 9781584262626
Category : Medical
Languages : en
Pages : 744

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2022 Hospital Compliance Assessment Workbook

2022 Hospital Compliance Assessment Workbook PDF Author: Joint Commission Resources
Publisher:
ISBN: 9781635852448
Category :
Languages : en
Pages :

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Guide to Clinical Documentation

Guide to Clinical Documentation PDF 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.

Care of the Acutely Ill Adult

Care of the Acutely Ill Adult PDF Author: Fiona Creed
Publisher: Oxford University Press
ISBN: 0192527088
Category : Medical
Languages : en
Pages : 481

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Book Description
This key textbook equips all nurses with the knowledge and skills required to care for the deteriorating patient in the clinical environment. The book emphasises the importance of systematic assessment, interpretation of clinical signs of deterioration, and the need to escalate the patient in a timely manner. Using a unique system-based approach, each chapter contains structured learning outcomes and concludes with a competence-based skills assessment to perfect the reader's practice skills. These skills are recommended as essential for every nurse in an acute area and key to successful practice. Restructured for ease of use, this new edition has been fully updated to match current guidelines, with new chapters on pain management and the ethics and ceilings of treatment. Written by senior nurses, this key textbook uses real life case studies to link knowledge to practice and is essential reading for all nurses working in acute care settings and undertaking study in the field.

Taking Action Against Clinician Burnout

Taking Action Against Clinician Burnout PDF Author: National Academies of Sciences, Engineering, and Medicine
Publisher: National Academies Press
ISBN: 0309495474
Category : Medical
Languages : en
Pages : 335

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Book Description
Patient-centered, high-quality health care relies on the well-being, health, and safety of health care clinicians. However, alarmingly high rates of clinician burnout in the United States are detrimental to the quality of care being provided, harmful to individuals in the workforce, and costly. It is important to take a systemic approach to address burnout that focuses on the structure, organization, and culture of health care. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being builds upon two groundbreaking reports from the past twenty years, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, which both called attention to the issues around patient safety and quality of care. This report explores the extent, consequences, and contributing factors of clinician burnout and provides a framework for a systems approach to clinician burnout and professional well-being, a research agenda to advance clinician well-being, and recommendations for the field.

How to Practice Academic Medicine and Publish from Developing Countries?

How to Practice Academic Medicine and Publish from Developing Countries? PDF Author: Samiran Nundy
Publisher: Springer Nature
ISBN: 9811652481
Category : Medical
Languages : en
Pages : 475

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Book Description
This is an open access book. The book provides an overview of the state of research in developing countries – Africa, Latin America, and Asia (especially India) and why research and publications are important in these regions. It addresses budding but struggling academics in low and middle-income countries. It is written mainly by senior colleagues who have experienced and recognized the challenges with design, documentation, and publication of health research in the developing world. The book includes short chapters providing insight into planning research at the undergraduate or postgraduate level, issues related to research ethics, and conduct of clinical trials. It also serves as a guide towards establishing a research question and research methodology. It covers important concepts such as writing a paper, the submission process, dealing with rejection and revisions, and covers additional topics such as planning lectures and presentations. The book will be useful for graduates, postgraduates, teachers as well as physicians and practitioners all over the developing world who are interested in academic medicine and wish to do medical research.

Medical Record Auditor

Medical Record Auditor PDF Author: Deborah J. Grider
Publisher: American Medical Association Press
ISBN: 9781603592949
Category : Medical
Languages : en
Pages : 0

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Book Description
"This book helps readers understand the principles of medical record documentation and chart auditing. It introduces readers to principles of medical record documentation and how to conduct a medical record chart review in the physcian's or outpatient office"--Provided by publisher.

Principles and Practice of Hospital Medicine

Principles and Practice of Hospital Medicine PDF Author: Sylvia McKean
Publisher: McGraw Hill Professional
ISBN: 0071603905
Category : Medical
Languages : en
Pages : 2351

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Book Description
The definitive guide to the knowledge and skills necessary to practice Hospital Medicine Presented in full color and enhanced by more than 700 illustrations, this authoritative text provides a background in all the important clinical, organizational, and administrative areas now required for the practice of hospital medicine. The goal of the book is provide trainees, junior and senior clinicians, and other professionals with a comprehensive resource that they can use to improve care processes and performance in the hospitals that serve their communities. Each chapter opens with boxed Key Clinical Questions that are addressed in the text and hundreds of tables encapsulate important information. Case studies demonstrate how to apply the concepts covered in the text directly to the hospitalized patient. Principles and Practice of Hospital Medicine is divided into six parts: Systems of Care: Introduces key issues in Hospital Medicine, patient safety, quality improvement, leadership and practice management, professionalism and medical ethics, medical legal issues and risk management, teaching and development. Medical Consultation and Co-Management: Reviews core tenets of medical consultation, preoperative assessment and management of post-operative medical problems. Clinical Problem-Solving in Hospital Medicine: Introduces principles of evidence-based medicine, quality of evidence, interpretation of diagnostic tests, systemic reviews and meta-analysis, and knowledge translations to clinical practice. Approach to the Patient at the Bedside: Details the diagnosis, testing, and initial management of common complaints that may either precipitate admission or arise during hospitalization. Hospitalist Skills: Covers the interpretation of common “low tech” tests that are routinely accessible on admission, how to optimize the use of radiology services, and the standardization of the execution of procedures routinely performed by some hospitalists. Clinical Conditions: Reflects the expanding scope of Hospital Medicine by including sections of Emergency Medicine, Critical Care, Geriatrics, Neurology, Palliative Care, Pregnancy, Psychiatry and Addiction, and Wartime Medicine.

The Computer-Based Patient Record

The Computer-Based Patient Record PDF Author: Committee on Improving the Patient Record
Publisher: National Academies Press
ISBN: 030957885X
Category : Medical
Languages : en
Pages : 257

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Book Description
Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.