guide to clinical documentation

Download Book Guide To Clinical Documentation in PDF format. You can Read Online Guide To Clinical Documentation here in PDF, EPUB, Mobi or Docx formats.

Guide To Clinical Documentation

Author : Debra Sullivan
ISBN : 9780803629974
Genre : Medical
File Size : 72. 98 MB
Format : PDF, ePub, Mobi
Download : 767
Read : 1105

Download Now


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 : 34. 18 MB
Format : PDF
Download : 718
Read : 1076

Download Now


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 Clinical Documentation Improvement Specialist S Guide To Icd 10

Author : Glenn Krauss
ISBN : 9781601468178
Genre : Medical
File Size : 67. 98 MB
Format : PDF, Mobi
Download : 547
Read : 850

Download Now


Take charge of ICD-10 documentation requirements The implementation of ICD-10 brings with it new documentation requirements that will have a significant impact on the work of your CDI team. The higher degree of specificity of information needed to code accurately will have a direct correlation to reimbursement and compliance. CDI specialists need a firm understanding of the new code set, and the rules that govern it, to obtain the appropriate level of documentation from physicians. The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only book that addresses ICD-10 from the CDI point of view. Written by CDI experts, it explains the new documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. You'll find the specific documentation requirements to appropriately code conditions such as heart failure, sepsis, and COPD. Learn from your peers The Clinical Documentation Improvement Specialist's Guide to ICD-10 includes case studies from two hospitals that have already begun ICD-10 training so you can use their timelines as a blue print to begin your organization's training and implementation. ICD-10 implementation happens in 2013. It's not too soon to start developing the expertise and comfort level you'll need to manage this important industry change and help your organization make a smooth transition. Benefits: * Tailored exclusively for CDI specialists * Side-by-side comparison of what documentation is necessary now v. what will be required starting October 1, 2013 * Timelines to train physicians in new documentation requirements to ensure readiness by implementation date * Strategies and best practices to ensure physician buy-in

The Physician Advisor S Guide To Clinical Documentation Improvement

Author : Trey La Charite
ISBN : 1615693475
Genre : Medical
File Size : 22. 82 MB
Format : PDF, ePub, Mobi
Download : 618
Read : 1008

Download Now


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 : 67. 2 MB
Format : PDF, Mobi
Download : 359
Read : 316

Download Now



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 : 78. 10 MB
Format : PDF, ePub, Mobi
Download : 610
Read : 490

Download Now



Complete Guide To Documentation

Author : Lippincott Williams & Wilkins
ISBN : 1582555567
Genre : Medical
File Size : 45. 26 MB
Format : PDF, Mobi
Download : 124
Read : 433

Download Now


Thoroughly updated for its Second Edition, this comprehensive reference provides clear, practical guidelines on documenting patient care in all nursing practice settings, the leading clinical specialties, and current documentation systems. This edition features greatly expanded coverage of computerized charting and electronic medical records (EMRs), complete guidelines for documenting JCAHO safety goals, and new information on charting pain management. Hundreds of filled-in sample forms show specific content and wording. Icons highlight tips and timesavers, critical case law and legal safeguards, and advice for special situations. Appendices include NANDA taxonomy, JCAHO documentation standards, and documenting outcomes and interventions for key nursing diagnoses.

Medical Record Auditor Documentation Rules And Rationales W Exercises

Author : Deborah J. Grider
ISBN : 1622021010
Genre : Medical
File Size : 28. 53 MB
Format : PDF, ePub
Download : 415
Read : 977

Download Now



The Clinical Documentation Improvement Specialist S Guide To Icd 10

Author : Jennifer Avery
ISBN : 1615692002
Genre : Medical
File Size : 55. 19 MB
Format : PDF, ePub, Docs
Download : 261
Read : 1075

Download Now


Now in its second edition, The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only guide to address ICD-10 from the CDI point of view. Written by CDI experts and ICD-10 Boot Camp instructors, it explains the ICD-10 documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. You'll find the specific documentation requirements to appropriately code a variety of conditions. The CDI Specialist's Guide to ICD-10, 2nd edition, not only outlines the changes coming in October 2014, it provides detailed information on how to assess staffing needs, training requirements, and implementation strategies. The authors-an ICD-10 certified coder and CDI specialist-collaborated to create a comprehensive selection of ICD-10 sample queries facilities can download and use to jumpstart ICD-10 documentation improvement efforts. Develop the expertise and comfort level you'll need to manage this important industry change and help your organization make a smooth transition. The Clinical Documentation Improvement Specialist's Guide to ICD- 10, 2nd ed. is part of the library of products and services from the Association of Clinical Documentation Improvement Specialists (ACDIS). ACDIS members are CDI professionals who share the latest tested tips, tools, and strategies to implement successful CDI programs and achieve professional growth. Member benefits include a quarterly journal, members-only Web site, quarterly networking conference calls, discounts on conferences, and more. WHAT'S NEW? Completely revised to accommodate changes in ICD-10 implementation dates Dozens of targeted ICD-10 physician queries Updated ICD-10 benchmarking reports BENEFITS Sample ICD-10 queries Specificity requirements and clinical indicators by disease type and body system Staff training and assessment tools

Guide To Outpatient Clinical Documentation Improvement

Author : Ruthann Russo
ISBN : 1578393043
Genre : Medical
File Size : 37. 47 MB
Format : PDF, ePub
Download : 608
Read : 468

Download Now



Top Download:

Best Books