| Foreword |
|
v | |
| Reviewers |
|
vi | |
| Contents |
|
vii | |
| PART I: BACKGROUND INFORMATION |
|
1 | (30) |
|
CHAPTER 1 Introduction to Note Writing |
|
|
1 | (6) |
|
CHAPTER 2 Writing in a Medical Record |
|
|
7 | (4) |
|
CHAPTER 3 Medical Terminology |
|
|
11 | (6) |
|
|
|
13 | (4) |
|
CHAPTER 4 Using Abbreviations |
|
|
17 | (14) |
|
|
|
27 | (4) |
| PART II: DOCUMENTING TNE EXAMINATION |
|
31 | (82) |
|
CHAPTER 5 The Patient/Client Management Format: History |
|
|
31 | (16) |
|
|
|
35 | (12) |
|
CHAPTER 6 The Patient/Client Management Format: Writing Systems Review |
|
|
47 | (12) |
|
|
|
51 | (8) |
|
CHAPTER 7 The Patient' Client Management Format: Documenting Tests and Measures |
|
|
59 | (14) |
|
|
|
63 | (6) |
|
REVIEW WORKSHEET: Writing the History, Systems Review, and Tests and Measures |
|
|
69 | (4) |
|
CHAPTER 8 The SOAP Note: Stating the Problem |
|
|
73 | (2) |
|
CHAPTER 9 The SOAP Note: Writing Subjective (S) |
|
|
75 | (16) |
|
|
|
81 | (10) |
|
CHAPTER 10 The SOAP Note: Writing Objective (O) |
|
|
91 | (22) |
|
|
|
99 | (10) |
|
REVIEW WORKSHEET: Stating the Problem, S & O |
|
|
109 | (4) |
| PART II: DOCUMENTING THE EVALUATION (A) |
|
113 | (20) |
|
CHAPTER 11 Writing the Diagnosis Note |
|
|
113 | (4) |
|
CHAPTER 12 Writing the Prognosis |
|
|
117 | (16) |
|
|
|
119 | (8) |
|
REVIEW WORKSHEET: History, Systems Review, Tests & Measures, Diagnosis, Prognosis, Problem, S, O, A |
|
|
127 | (6) |
| PART IV: DOCUMENTING THE PLAN OF CARE (P) |
|
133 | (46) |
|
CHAPTER 13 Writing Expected Outcomes (Long-Term Goals) |
|
|
133 | (14) |
|
|
|
1139 | |
|
CHAPTER 14 Writing Anticipated Goals (Short-Term Goals) |
|
|
147 | (14) |
|
|
|
153 | (8) |
|
CHAPTER 15 Documenting Planned Interventions |
|
|
161 | (18) |
|
|
|
165 | (4) |
|
FINAL REVIEW WORKSHEET: Patient/Client Management Note: Examination, Evaluation, & Plan of Care |
|
|
169 | (10) |
| PART V: APPLICATIONS OF DOCUMENTATION SKILLS |
|
179 | (8) |
|
CHAPTER 16 Applications and Variations in Note Writing |
|
|
179 | (4) |
|
CHAPTER 17 Alternatives: Documentation Forms, Medicare Forms, and Computerized Documentation |
|
|
183 | (4) |
| APPENDIX A Answers to Worksheets |
|
187 | (16) |
| APPENDIX B Note Writing and the Process of Clinical Decision-Making |
|
203 | (1) |
| APPENDIX C Summary of the Patient/Client Management Note Contents |
|
204 | (4) |
| APPENDIX D Summary of the SOAP Note Contents |
|
208 | (5) |
| APPENDIX E Tips for Note Writing for Third-Party Payers |
|
213 | (2) |
| APPENDIX F Bibliography |
|
215 | |
Shopping Cart
Need Help? bookstore@ecampus.com
Copyright© 1999-2008
