Guide to Clinical Documentation

Debra D. Sullivan (Author)

9780803666627

Paperback / softback, published 16 August 2018

416 pages, 74 illustrations
27.9 x 21.6 x 1.9 cm, 0.953 kg

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

• 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. Prenatal Care Visits and Newborn Physical Examination
• 5. Pediatric Preventive Care Visits
• 6. Adult Preventive Care Visits
• 7. Older Adult 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
• 11. Documenting Inpatient Care
• 12. Discharging Patients from the Hospital
• Appendices
• A. Document Library
• B. A Guide to Sexual History Taking
• C. ISMP&
  rsquo
  s List of Error-Prone Abbreviations, Symbols, and Dose Designations
• Bibliography