Guide to Clinical Documentation

by Sullivan, Debra D.

• ISBN13: 9780803666627
• ISBN10: 0803666624
• Edition: 3rd
• Format: Paperback
• Copyright: 2018-08-16
• Publisher: F.A. Davis Company

Summary

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

Table of Contents

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. Documenting Prenatal Care and Visits and Newborn Physical Examination
Perinatal Events
5. Pediatric Preventive Care Visits
6. Adult Preventive Care Visits
7. Older Adult Preventative Care 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’s List of Error-Prone Abbreviations, Symbols, and Dose Designations
Bibliography
Index