Clinical Documentation

3rd Edition

by Debra D. Sullivan

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.

• Learning objectives in eachchapter to help you recognize important concepts at the beginning of thechapter, and reinforce what is summarized at the end of each chapter
• Coverage of -problem-oriented medical records, patients with multiple complaints or multiple conditions
• Hands-on, problem-based exercises
• Worksheets at the end of each chapter
• Examples of “good” and “bad” documentation for evaluation
• Real-life case studies that illustrate the potential consequences of poor or inaccurate documentation.
• Explanations of use and terminology of ICD-10-CM codes in billing
• Boxes highlighting medicolegal considerations.