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Sullivan Debra D. (ed.) Guide to Clinical Documentation

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Sullivan Debra D. (ed.) Guide to Clinical Documentation
3rd edition. — F. A. Davis Company, 2019. — 417 p. — ISBN: 978-0-8036-6662-7
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.
Foundations of Documentation
Medicolegal Principles of Documentation
The Comprehensive History and Physical Examination
SOAP Notes
Documentation Related to Outpatient Care
Documenting Prenatal Care and Perinatal Events
Pediatric Preventive Care Visits
Adult Preventive Care Visits
Older Adult Preventive Care Visits
Outpatient Charting and Communication
Prescription Writing and Electronic Prescribing
Documentation Related to Inpatient Care
Admitting a Patient to the Hospital
Documenting Inpatient Care
Discharging Patients from the Hospital
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