Guide to Clinical Documentation PDF Download
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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: 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: Sherry Borcherding
Publisher: SLACK Incorporated
ISBN: 9781556427794
Category : Allied health personnel
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. "Answers" are provided for all worksheets so that the text can be used for independent study if desired. 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: 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: 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: Nancy Sidell
Publisher: N A S W Press
ISBN: 9780871014047
Category : Communication in social work
Languages : en
Pages : 0
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Book Description
Social work practitioners spend a lot of time documenting services they provide, but many are ill-prepared for this practice responsibility. In Social Work Documentation: A Guide to Strengthening Your Case Recording, Nancy Sidell has written the perfect, practical, how-to book on developing effective documentation. Regardless of the practice setting, clinical specialty, and documentation format, this book will help to build better recording skills. In her book, Social Work Documentation: A Guide to Strengthening Your Case Recording, Dr. Sidell provides a clear, concise, and thorough justification of why documentation is important, the different styles used to record client information, and an array of valuable case exercises to work through. Particularly useful is the inclusion of current and relevant examples of documentation that represent a range of practice fields at all levels of social work intervention to include: micro, mezzo, and macro. Woven throughout the workbook are ethical, legal, and supervisory situations that occur in practice that require the reader to critically think about how they would respond. This book is suitable and highly recommended for undergraduate and graduate education, agency trainings, and continuing education courses.
Author: Mia Erickson
Publisher: SLACK Incorporated
ISBN: 1617110086
Category : Medical
Languages : en
Pages : 176
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Book Description
Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The new Second Edition of Documentation Basics: A Guide for the Physical Therapist Assistant continues the path of teaching the student and clinician documentation from A to Z.
Author: Lori Quinn
Publisher: Elsevier Health Sciences
ISBN: 0323266363
Category : Medical
Languages : en
Pages : 280
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Book Description
Four NEW chapters address additional aspects of documentation that rehabilitation professionals will encounter in practice: Legal aspects of documentation Documentation in pediatrics Payment policy and coding Computerized documentation
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: 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.
