Guide to clinical documentation
"Here's your guide to developing the skills you need to master the increasingly complex challenges of documenting patient care. Step by step, a straightforward 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"--
Read More ↓Title Statements
- Full title :Guide to clinical documentation / Debra D. Sullivan.
Summary
"Here's your guide to developing the skills you need to master the increasingly complex challenges of documenting patient care. Step by step, a straightforward 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"--
Read More ↓Edition Statements
- Publication Date:2019
- Edition:Third edition
Publication Statements
- Publisher(s):FA Davis Company
- Place of Publication:Philadelphia
- Language:eng
- Publication Date:2019
The Physical Object
- Description:1 online resource (xxi, 393 pages) : : illustrations
Edition Identifiers
- ISBN:9780803669994, 0803669992
- oclc:on1032291972
- LC Classification:R697.P45
- Dewey Decimal:651.5/04261
Table of Contents
Medicolegal principles of documentation -- The comprehensive history and physical examination -- SOAP notes -- Prenatal care visits and newborn physical examination -- Pediatric preventive care visits -- Adult preventive care visits -- Older adult visits -- Outpatient charting and communication -- Prescription writing and electronic prescribing -- Admitting a patient to the hospital -- Documenting inpatient care -- Discharging patients from the hospital.
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