Guide to Clinical Documentation, 3rd Edition

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
Learning objectives in eachchapter to help you recognize important concepts at the beginning of thechapter, and reinforce what is summarized at the end of each chapter
Coverage of -problem-oriented medical records, patients with multiple complaints or multiple conditions
Hands-on, problem-based exercises
Worksheets at the end of each chapter
Examples of "good" and "bad" documentation for evaluation
Real-life case studies that illustrate the potential consequences of poor or inaccurate documentation
Explanations of use and terminology of ICD-10-CM codes in billing
Boxes highlighting medicolegal considerations