guide to clinical documentation

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Guide To Clinical Documentation

Author : Debra Sullivan
ISBN : 9780803629974
Genre : Medical
File Size : 84. 19 MB
Format : PDF
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Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.

Guide To Clinical Documentation

Author : Debra D Sullivan
ISBN : 9780803669994
Genre : Medical
File Size : 78. 9 MB
Format : PDF, ePub, Mobi
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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.

The Physician Advisor S Guide To Clinical Documentation Improvement

Author : Trey La Charite
ISBN : 1615693475
Genre : Medical
File Size : 45. 90 MB
Format : PDF, ePub, Mobi
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The Physician Advisor's Guide to Clinical Documentation Improvement Physician advisors are not just needed for case management anymore. ICD-10-CM/PCS and the changing landscape of healthcare reimbursement make their input invaluable in the realm of CDI and coding, too. This book will help your physician advisors quickly understand the vital role they play and how they can not only help improve healthcare reimbursement, but also reduce claims denials and improve the quality of care overall. This book will: * Provide job descriptions and sample roles and responsibilities for CDI physician advisors * Outline the importance of CDI efforts in specific relation to the needs and expectations of physicians * Highlight documentation improvement focus areas by Major Diagnostic Category * Review government initiatives and claims denial patterns, providing physician advisors concrete tools to sway physician documentation

The Writer S Handbook

Author : Jeff Griffith
ISBN : UOM:49015000867359
Genre : Language Arts & Disciplines
File Size : 53. 68 MB
Format : PDF, ePub, Docs
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A Practical Guide To Clinical Documentation In Behavioral Health Care

Author : Joint Commission on Accreditation of Healthcare Organizations
ISBN : 0866885056
Genre : Clinical health psychology
File Size : 20. 75 MB
Format : PDF, Docs
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Guide To Clinical Validation Documentation And Coding 2019

Author :
ISBN : 1622544064
Genre : Diagnosis related groups
File Size : 40. 56 MB
Format : PDF
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Resource added for the Health Information Technology program 105301.​

Guide To Clinical Validation Documentation And Coding 2018

Author :
ISBN : 1622543335
Genre :
File Size : 76. 70 MB
Format : PDF, Kindle
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Documentation For Rehabilitation E Book

Author : Lori Quinn
ISBN : 9780323266369
Genre : Medical
File Size : 77. 16 MB
Format : PDF
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Ensure confident clinical decisions and maximum reimbursement in a variety of practice settings such as acute care, outpatient, home care, and nursing homes with the only systematic approach to documentation for rehabilitation professionals! Revised and expanded, this hands-on textbook/workbook provides a unique framework for maintaining evidence of treatment progress and patient outcomes with a clear, logical progression. Extensive examples and exercises in each chapter reinforce concepts and encourage you to apply what you’ve learned to realistic practice scenarios. UNIQUE! Combination textbook/workbook format reinforces your understanding and tests your ability to apply concepts through practice exercises. UNIQUE! Systematic approach to documenting functional outcomes provides a practical framework for success in numerous practice settings. Case studies show you how to format goals through realistic client examples. Practice exercises provide valuable experience applying concepts to common clinical problems. Four NEW chapters address additional aspects of documentation that rehabilitation professionals will encounter in practice: Legal aspects of documentation Documentation in pediatrics Payment policy and coding Computerized documentation

Documentation For Rehabilitation

Author : Lori Quinn
ISBN : 9780323312332
Genre : Communication in medicine
File Size : 75. 21 MB
Format : PDF, ePub, Mobi
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Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you've learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning. A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model - the one adopted by the APTA. Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings. Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies - especially important when insurance companies require evidence of functional progress in order to provide reimbursement. Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts. NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries. UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding. EXPANDED number of case examples covers an even broader range of clinical practice areas.

The Counselor S Steps For Progress Notes

Author : Rhonda Sutton
ISBN : 1514643588
Genre : Counseling
File Size : 38. 4 MB
Format : PDF
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Dr. Rhonda Sutton's second edition of the straightforward guide to progress notes includes additional examples, information, documentation, and clinical language that expands on the utility and readability of the first book. Additional case studies provide examples of how to use the STEPs to format notes. New chapters include information on clinical language and documentation. This book covers everything about progress notes, from how to write them, to how to store them, and even what to do when someone requests to them. In addition, clinical terms and abbreviations are included as well as suggestions for other clinical documentation such as termination letters, privacy statements, and professional disclosure statements. Suited for all types of mental health clinicians, this book will help therapists improve upon their progress notes and other forms of clinical documentation.

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