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Guide to Clinical Documentation Third Edition [Pehme köide]

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  • Formaat: Paperback / softback, 416 pages, kõrgus x laius x paksus: 279x216x19 mm, kaal: 953 g, 74 illustrations
  • Ilmumisaeg: 30-Aug-2018
  • Kirjastus: F.A. Davis Company
  • ISBN-10: 0803666624
  • ISBN-13: 9780803666627
Teised raamatud teemal:
Guide to Clinical Documentation Third EditionSuurem pilt
  • Formaat: Paperback / softback, 416 pages, kõrgus x laius x paksus: 279x216x19 mm, kaal: 953 g, 74 illustrations
  • Ilmumisaeg: 30-Aug-2018
  • Kirjastus: F.A. Davis Company
  • ISBN-10: 0803666624
  • ISBN-13: 9780803666627
Teised raamatud teemal:
Püsilink: https://www.kriso.ee/db/9780803666627.html
Märksõnad:

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

Part I: Foundations of Documentation
Chapter I Medicolegal Principles of Documentation
1(22)
Learning Outcomes
1(1)
Introduction
1(1)
Medical Considerations of Documentation
2(1)
Legal Considerations of Documentation
2(1)
Other Purposes of Documentation
3(1)
General Principles of Documentation
3(2)
Medical Coding and Billing
5(3)
Evaluation and Management Services
5(1)
International Classification of Diseases Coding
6(2)
Electronic Medical Records
8(2)
Benefits of Electronic Medical Records
8(1)
Barriers to Electronic Medical Records
9(1)
Interoperability
9(1)
Meaningful Use
9(1)
Health Insurance Portability and Accountability Act (HIPAA)
10(4)
Health Insurance Portability
10(1)
Electronic Health-Care Transactions
10(1)
The Privacy Rule
10(3)
Security Rule
13(1)
Summary of the Act
14(1)
Summary
14(1)
Worksheets
15(8)
Chapter 2 The Comprehensive History and Physical Examination
23(22)
Learning Outcomes
23(1)
Introduction
23(1)
Components of a Comprehensive History and Physical Examination
23(9)
History
24(5)
Physical Examination
29(3)
Laboratory and Diagnostic Studies
32(1)
Problem List,Assessment, and Differential Diagnosis
32(1)
Plan of Care
32(1)
Sample Comprehensive History and Physical Examination
32(1)
Summary
32(5)
Worksheets
37(8)
Chapter 3 SOAP Notes
45(34)
Learning Outcomes
45(1)
Introduction
45(1)
Subjective
45(3)
Analyzing Documentation
47(1)
Objective
48(4)
Formats for Documenting Objective Information
49(1)
Documenting Diagnostic Test Results
50(1)
Interventions Done During the Visit
50(2)
Assessment
52(2)
Differential Diagnosis
53(1)
Plan
54(4)
Laboratory and Diagnostic Tests
54(1)
Consults
54(1)
Therapeutic Modalities
55(1)
Health Promotion and Disease Prevention
55(1)
Patient Education
55(1)
Follow-Up Instructions
56(2)
Summary
58(1)
Worksheets
59(20)
Part II: Documentation Related to Outpatient Care
Chapter 4 Documenting Prenatal Care and Perinatal Events
79(14)
Learning Outcomes
79(1)
Introduction
79(1)
Documentation of Prenatal Care
80(3)
Demographic Information
80(1)
Maternal History
80(1)
Physical Examination
81(1)
Laboratory Data and Diagnostic Tests
82(1)
Health Promotion and Disease Prevention
83(1)
Documentation of Perinatal and Postpartum Care
83(4)
Delivery Note
83(3)
Postpartum Note
86(1)
Newborn Physical Examination
87(1)
Summary
87(2)
Worksheets
89(4)
Chapter 5 Pediatric Preventive Care Visits
93(32)
Learning Outcomes
93(1)
Introduction
93(1)
Components of Pediatric Preventive Care Visits
94(12)
Growth Screening
94(4)
Developmental Screening
98(1)
Laboratory Screening Tests
99(1)
Assessing Vaccination Status
100(1)
Anticipatory Guidance
100(2)
Risk Factor Identification
102(4)
Age-Specific Physical Examinations
106(1)
Pediatric Sports Preparticipation Physical Examination
106(3)
Summary
109(2)
Worksheets
111(14)
Chapter 6 Adult Preventive Care Visits
125(28)
Learning Outcomes
125(1)
Introduction
125(1)
Documenting Preventive Care
126(13)
Risk Factor Identification Based on Personal History
126(9)
Risk Factor Identification Based on Family History
135(1)
Risk Factor Identification Based on Screening Tests
135(1)
Gender-Specific Screening
136(3)
Health Education and Counseling
139(1)
Assessing Vaccination Status
139(1)
Summary
139(2)
Worksheets
141(12)
Chapter 7 Older Adult Preventive Care Visits
153(20)
Learning Outcomes
153(1)
Introduction
153(1)
Assessing Older Adult Risk Factors Through History Taking
153(7)
Medication Use
153(3)
Functional Impairment
156(1)
Nutrition
156(3)
Sensory Deficit Screening
159(1)
Mental Health Screening
160(1)
Geriatric Syndromes
160(1)
Assessing Older Adult Risk Factors Through Physical Examination
160(2)
Sensory Examinations
161(1)
Balance and Mobility Assessment
162(1)
Cognitive Assessment
162(1)
Additional Screening
162(1)
Pre-operative Evaluation of Older Adults
162(3)
Anticipating Future Needs
165(1)
Advance Directives
165(1)
Hospice and Palliative Care
166(1)
Summary
166(1)
Worksheets
167(6)
Chapter 8 Outpatient Charting and Communication
173(22)
Learning Outcomes
173(1)
Introduction
173(1)
Components of the Medical Record
173(6)
Problem List
173(3)
Medication List
176(3)
Flow Sheets
179(1)
Demographic and Billing Information
179(1)
Results of Laboratory Studies and Other Diagnostic Tests
179(1)
Noncompliance With Medical Treatment
179(3)
Communication With Other Providers
182(1)
Prior Medical Records
183(1)
Documenting Communications With Patients
183(4)
Telephone Communication
183(2)
Electronic Mail
185(2)
Patient Portal
187(1)
Social Media
187(1)
Benefits of Social Media
187(1)
Concerns About Social Media
188(1)
Provisions for Using Social Media
188(1)
Summary
188(1)
Worksheets
189(6)
Chapter 9 Prescription Writing and Electronic Prescribing
195(22)
Learning Outcomes
195(1)
Introduction
195(1)
Federal and State Regulations and Prescribing Authority
196(1)
Safeguards for Prescribers
197(2)
Controlled and Noncontrolled Substances
199(1)
Elements of a Prescription
199(1)
Writing Prescriptions for Noncontrolled Medications
199(2)
Prescriber Identification
199(1)
Patient Identification
199(1)
Inscription
200(1)
Subscription
200(1)
Signa or sig
200(1)
Indication
200(1)
Refill Information
200(1)
Generic Substitution
201(1)
Warnings
201(1)
Container Information
201(1)
Signature
201(1)
Writing Prescriptions for Controlled Medications
201(1)
Common Errors in Prescription Writing
202(1)
Electronic Prescribing
203(3)
Federal Initiatives for Electronic Prescribing
204(1)
Qualified Electronic Prescribing
204(1)
Benefits of E-Prescribing
205(1)
Barriers to E-Prescribing
206(1)
Summary
206(1)
Worksheets
207(10)
Part III: Documentation Related to Inpatient Care
Chapter 10 Admitting a Patient to the Hospital
217(40)
Learning Outcomes
217(1)
Introduction
217(1)
Admission History and Physical Examination
218(5)
Medical Admission History and Physical Examination
218(3)
Surgical Admission History and Physical Examination
221(2)
Sample H&P
223(1)
Admission Orders
223(6)
Admit
227(1)
Diagnosis
227(1)
Condition
227(1)
Activity
227(1)
Vital Signs
227(1)
Allergies
228(1)
Diet
228(1)
Interventions
228(1)
Medications
228(1)
Procedures
229(1)
Laboratory and Other Diagnostic Studies
229(1)
Special Instructions
229(1)
Perioperative Orders
229(5)
Admit
230(1)
Diagnosis
230(1)
Condition
230(1)
Activity
230(1)
Vital Signs
230(1)
Allergies
230(1)
Diet
230(2)
Interventions
232(1)
Medications
232(1)
Procedures
233(1)
Laboratory and Other Diagnostic Studies
233(1)
Special Instructions
234(1)
Computerized Physician Order Entry
234(3)
Benefits of CPOE
235(1)
Challenges and Barriers to CPOE
235(2)
Admit Notes
237(1)
Summary
238(1)
Worksheets
239(18)
Chapter 11 Documenting Inpatient Care
257(28)
Learning Outcomes
257(1)
Introduction
257(1)
Daily Progress Note
257(3)
Content of a Daily Progress Note
257(3)
Daily Orders
260(6)
Consult Note
266(5)
Full Operative Report and Operative Note
271(1)
Other Types of Documents
272(2)
Procedure Note
272(2)
Summary
274(1)
Worksheets
275(10)
Chapter 12 Discharging Patients from the Hospital
285(24)
Learning Outcomes
285(1)
Introduction
285(1)
Discharge Orders
285(3)
Disposition
286(1)
Activity Level
286(1)
Diet
286(1)
Medication Reconciliation
286(1)
Follow-Up Care and Notification Instructions
287(1)
Discharge Summary
288(3)
Dates of Admission and Discharge
288(1)
Admitting and Discharge Diagnosis
(or Diagnoses)
288(1)
Attending Physician, Primary Provider, and Consulting Physician
289(1)
Procedures
289(1)
Brief History, Pertinent Physical Examination Findings, and Pertinent Laboratory Values
289(1)
Hospital Course
290(1)
Condition at Discharge
291(1)
Disposition, Discharge Medications, Discharge Instructions, and Follow-Up Instructions
291(1)
Patient Leaving Before Discharge
291(3)
AMA
291(2)
Elopement
293(1)
Summary
294(1)
Worksheets
295
Appendices
Appendix A Document Library
309(64)
Appendix B A Guide to Sexual History Taking
373(2)
Appendix C ISMP's List of Error-Prone Abbreviations, Symbols, and Dose Designations
375(2)
Bibliography 377(10)
Index 387