guide to clinical documentation

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Guide To Clinical Documentation

Author : Debra Sullivan
ISBN : 9780803629974
Genre : Medical
File Size : 80. 36 MB
Format : PDF, Mobi
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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 : 71. 82 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 : 58. 87 MB
Format : PDF, Kindle
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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

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 : 30. 13 MB
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Guide To Clinical Validation Documentation And Coding 2018

Author :
ISBN : 1622543335
Genre :
File Size : 90. 23 MB
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Documentation For Rehabilitation

Author : Lori Quinn
ISBN : 9780323312349
Genre : Medical
File Size : 82. 9 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.

Clinical Care Classification Ccc System Manual

Author : Virginia Saba, EdD, RN, FAAN
ISBN : 0826103545
Genre : Medical
File Size : 39. 1 MB
Format : PDF
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Designated a Doody's Core Title! The Preeminent Nursing Terminology Classification System "The Clinical Care Classification (CCC) System described in this manual is the only standard coded nursing terminology that is based on sound research using the nursing process model framework and that meets the Patient Medical Record Information (PMRI) comparability requirement. The CCC System allows patient care data generated by nurses to be incorporated into the PMRI database, and enables nurses' contributions to patient outcomes to be studied and acknowledged." -- From the Foreword by Sheryl L. Taylor, BSN, RN, Senior Consultant, Farrell Associates TESTIMONIES: "ABC Coding Solutions-Alternative Link developed ABC codes for nursing in collaboration with Dr. Virginia Saba, developer of the CCC system. Approximately two hundred ABC codes were developed from the CCC System of Nursing Interventions to accurately document nursing and integrative health care processes, classify and track clinical care, and develop evidence-based practice models, thus filling significant gaps in older medical code sets." --Connie Koshewa, Practitioner Relations Director, ABC Coding Solutions-Alternative Link "The International Classification for Nursing Practice (ICNPÆ) is a program of the International Council of Nurses (ICN). One of the first steps in the development of the ICNPÆ was to collect and compare all the nursing concepts in existing nursing terminologies, including the CCC. To facilitate the goal of ICNPÆ as a unified nursing language system, a project is under way to map the CCC to the ICNPÆ Version 1.0. This work will facilitate evaluation and ongoing development of both terminologies and allow ICN to compare data using CCC codes with data from other standard nursing terminologies." --Amy Coenen, PhD, RN, FAAN, Director, ICNPÆ Program, International Council of Nurses

Documentation For Rehabilitation

Author : Lori Quinn
ISBN : 1416062211
Genre : Medical
File Size : 35. 47 MB
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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

The Clinical Documentation Improvement Specialist S Guide To Icd 10

Author : Glenn Krauss
ISBN : 9781601468178
Genre : Medical
File Size : 45. 76 MB
Format : PDF, ePub
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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

Guide To Clinical Validation Documentation And Coding 2017

Author :
ISBN : 1622542967
Genre :
File Size : 61. 19 MB
Format : PDF
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