Guide to clinical documentation
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.
Read More ↓Title Statements
- Full title :Guide to clinical documentation / Debra Sullivan.
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.
Read More ↓Edition Statements
- Publication Date:2018.
- Edition:3rd ed
Publication Statements
- Publisher(s):FA Davis Company
- Place of Publication:Philadelphia
- Language:eng
- Publication Date:2018.
Notes
Chapter 7 Older Adult Preventive Care Visits.
The Physical Object
- Description:1 online resource (417 pages)
Edition Identifiers
- ISBN:9780803669994, 0803669992
- oclc:on1057676718
Table of Contents
Cover; Title Page; Copyright; Dedication; Reviewers; Acknowledgments; Brief Contents; Contents; Introduction; PART I Foundations of Documentation; Chapter 1 Medicolegal Principles of Documentation; LEARNING OUTCOMES; Introduction; Medical Considerations of Documentation; Legal Considerations of Documentation; Other Purposes of Documentation; General Principles of Documentation; Medical Coding and Billing; Evaluation and Management Services; International Classification of Diseases Coding; Electronic Medical Records; Benefits of Electronic Medical Records.
Barriers to Electronic Medical RecordsInteroperability; Meaningful Use; Health Insurance Portability and Accountability Act (HIPAA); Health Insurance Portability; Electronic Health-Care Transactions; The Privacy Rule; Security Rule; Summary of the Act; Summary; Worksheets; Chapter 2 The Comprehensive History and Physical Examination; LEARNING OUTCOMES; Introduction; Components of a Comprehensive History and Physical Examination; History; Physical Examination; Laboratory and Diagnostic Studies; Problem List, Assessment, and Differential Diagnosis; Plan of Care.
Sample Comprehensive History and Physical ExaminationSummary; Worksh…
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