Guide To Clinical Documentation PDF

Guide to Clinical Documentation 2nd Edition PDF

Edition 2nd edition
Pages288 pages
ISBN• ISBN-10: 0803625839
• ISBN-13: 978-0803625839
Book nameGuide to clinical documentation
Language English
Publisher F.A. Davis Company; 2 edition (December 22, 2011)
Author:Debra D. Sullivan PhD RN PA-C


This book is a complete guide to the one who is willing to learn document patient’s care. The content will prepare you enough efficiently to handle hospital settings related to children or adults.

The sample notes, EMR activities and writing exercises provided in this handy guide are enough to polish your concepts. Deeply Go through the content of Guide to clinical documentation 2nd edition pdf and you will learn physical examination, how to document history, writing prescriptions and SOAP notes etc. let’s explore further about the book by going through the description and table of contents.

Key Features:

  • This edition is deeply revised and upgraded. All the content provided in this book is up-to-date.
  • In-depth coverage has been given to each and every document. You will find more documentation samples inside. It will increase the ability to analyze and imitate.
  • Real-life- case studies are added in Guide to clinical documentation 2nd edition pdf to enhance your skills to learn more via real incidence.
  • The usage of ICD-10-CM terminology has explained.
  • Text Boxes are inserted in between the content to highlight medico-legal consideration.
  • You will get knowledge about commonly used symbols and medical abbreviations.
  • Multiple- problems oriented cases are added in the content to gain more experience.
  • Learning objectives are added in each chapter as it helps in self-assessment.
  • Many worksheets and exercises are added in each chapter. It will help you to correct documentation.

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Table of Contents

  1. Medico-legal Principles of Documentation
  2. The Comprehensive History and Physical
  3. Adult Preventative Care Visits
  4. Pediatric Preventative Care Visits
  5. SOAP Notes
  6. Outpatient Charting and Communications
  7. Admitting a Patient to the Hospital
  8. Documenting Daily Rounds and Other Events
  9. Discharging Patients from the Hospital
  10. Prescription Writing and Electronic Prescribing


Adult Prevention Care Timeline

A Guide to Sexual History

Taking Suggestions for Dictating Medical Records

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations

Worksheet Answer Key




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