Get Free Ebook Guide to Clinical Documentation
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Guide to Clinical Documentation
Get Free Ebook Guide to Clinical Documentation
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Product details
Paperback: 416 pages
Publisher: F.A. Davis Company; 3 edition (August 16, 2018)
Language: English
ISBN-10: 0803666624
ISBN-13: 978-0803666627
Product Dimensions:
8.5 x 0.8 x 11 inches
Shipping Weight: 2.1 pounds (View shipping rates and policies)
Average Customer Review:
4.6 out of 5 stars
20 customer reviews
Amazon Best Sellers Rank:
#32,331 in Books (See Top 100 in Books)
This book has SO much more information in it than I anticipated. I wish I would have come across this sooner in my NP program. I actually wish that my university would have made this book a requirement as I definitely feel it has improved my clinical documentation in my practicum and my SOAP note assignments.
I bought this for school as an assignment that needed to be completed. SOAP notes are certainly subjective so be careful following these outlines. also listen to what your provider/professor wants and expects from the a SOAP.
It had a lot of helpful information. I do recommend for NP school!
This was provided to me specifically to create a review. That said, I always try to be honest and open in all my reviews.I love this guide.The expressed purpose of it is to act as a workbook for medical professionals learning about clinical documentation.I am not in the medical community, but the Reasonable Reviewer couple does have a set of aging parents who need increased medical care, and we are both writers. This book greatly increased our awareness of things that we could do to aid our parents as well as being full of just helpful suggestions.(Please see the enclosed pictures.)It weighs in at 391 pages and covers incredibly useful items from sleep aids to cultural questionnaires.We are using the guide as a way of adding realism to medical discussions in our stories.All in all, this is a wonderful resource.I highly recommend it.
This wasn't quite what I was hoping for in particular, however, it is a fantastic resource book nonetheless. I was hoping to use this book as a guide and cited resource for writing educational and training materials. I want to help nurses improve their EMR documentation in clinic settings. This book is written in more of a textbook style as related to taking a very broad spectrum course and the focus is more for APRN's, PA's and Physicians. There is great information and applications to be extrapolated from this resource, but I do not find the information to be as handy or applicable for my needs. If you are looking for information about; taking histories and physicals across various ages, populations, health concerns and charting for diagnosis code support, therapeutic regimen guidelines, medication regimens and interventional considerations, then this book will be very useful to you. This book covers so much information and so many topics, but I was hoping to find very specific guidelines and recommendations for nurses for legal, accurate, efficient and sufficient EMR charting for only medical office/clinic settings. Most documentation assistance for nurses that I have come across focuses on hospital, long term care, or home care settings.
This is more of a textbook than a guide, aimed at RNs, PA’s, Nurse Practicitioners, and MDs. There is a lot of medical jargon that is presented as-is without a glossary, so it’s meant for those already studying or practicing in the field. It goes without saying that precision is vital when it comes to clinical documentation – not only as as an aid to health professionals but also its possible use in cases of medical malpractice or ligitation.Each chapter begins with a list of bulleted points (outcomes) that the reader should absorb after finishing the chapter. In addition, there are worksheets that test your knowledge of what you’ve learned (the answers are online, not in the book, so you can’t give up easily). What I found most useful were the examples of various documents used in admitting patients, charting their medical exams, progress and history, discharge notes, prescription formats, and detailed case histories for physicians to review. It also includes information on coding used by physicians as well as insurance companies.All of it is presented in a tight format, so the book is not as thick as it could be. It’s a great resource for those already in the field or studying to enter it.
This book would be great just to put on a unit and let nurses read at their leisure. (If they ever have any.) I would want this in any unit Library. This book was written for advanced degree students and nurse practitioners, but as a former Hospital supervisor, I would have really loved to have this book on my bookshelf for reference. I think nurse educators would all benefit from the book as well.There's a few things but I would love to pass around the units, I like the charts on common misinterpretations that lead to medication errors.Why the book is about documentation it's also a rich source of assessment and screening tools. One can sit with us book for 15 minutes and learn all sorts of new things.The book does include worksheets without any real answers that are primarily directed at students. Professional staff may not benefit from this necessarily, but there's so much of the book that is packed full of assessment tools that it still will have a lot of value to them.It does include really great info on HIPPA, with worksheets that could be modified for inservices. And another interesting addition is a lot of information on Medical coding. But even include a section on social media.Anyone that has to deal with JCAHO or other regulatory/accreditation surveys, or medical record audits my also find this book useful.
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