Documentation for Health Records PDF Download

Author: Cheryl Gregg Fahrenholz
Publisher:
ISBN: 9781584262626
Category : Medical
Languages : en
Pages : 744

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Author: Barbara Odom-Wesley
Publisher:
ISBN: 9781584261834
Category : Medical informatics
Languages : en
Pages : 538

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Author: Debra Sullivan
Publisher: F.A. Davis
ISBN: 0803629974
Category : Medical
Languages : en
Pages : 301

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Book Description
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.

Author: Agency for Healthcare Research and Quality/AHRQ
Publisher: Government Printing Office
ISBN: 1587634333
Category : Medical
Languages : en
Pages : 385

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Book Description
This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.

Author: Committee on Improving the Patient Record
Publisher: National Academies Press
ISBN: 030957885X
Category : Medical
Languages : en
Pages : 257

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Book Description
Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.

Author: Inc Peter Pauper Press
Publisher: Peter Pauper Press
ISBN: 9781441313843
Category :
Languages : en
Pages : 0

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Book Description
From babys well visits through the first 18 years, record your childs immunizations, measurements & percentiles, illnesses, instructions from the doctor (& questions to remember to ask), and more in this simple, attractive, and sturdy health journal. With tips and reminders, this little tracker provides the perfect place to record clear and concise medical history necessary for school, camp, college, insurance, a change of doctors, and personal reference. Small and thin enough to fit in a purse and a file, with archival paper to last a lifetime. Measures 5-1/2" wide x 8" high. 56 pages. Hardcover with elastic band closure. Inside back cover pocket.

Author: Donald E. Wiger
Publisher: John Wiley & Sons
ISBN: 0470527781
Category : Psychology
Languages : en
Pages : 338

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Book Description
All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.

Author: MIT Critical Data
Publisher: Springer
ISBN: 3319437429
Category : Medical
Languages : en
Pages : 435

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Book Description
This book trains the next generation of scientists representing different disciplines to leverage the data generated during routine patient care. It formulates a more complete lexicon of evidence-based recommendations and support shared, ethical decision making by doctors with their patients. Diagnostic and therapeutic technologies continue to evolve rapidly, and both individual practitioners and clinical teams face increasingly complex ethical decisions. Unfortunately, the current state of medical knowledge does not provide the guidance to make the majority of clinical decisions on the basis of evidence. The present research infrastructure is inefficient and frequently produces unreliable results that cannot be replicated. Even randomized controlled trials (RCTs), the traditional gold standards of the research reliability hierarchy, are not without limitations. They can be costly, labor intensive, and slow, and can return results that are seldom generalizable to every patient population. Furthermore, many pertinent but unresolved clinical and medical systems issues do not seem to have attracted the interest of the research enterprise, which has come to focus instead on cellular and molecular investigations and single-agent (e.g., a drug or device) effects. For clinicians, the end result is a bit of a “data desert” when it comes to making decisions. The new research infrastructure proposed in this book will help the medical profession to make ethically sound and well informed decisions for their patients.

Author: Fiona Creed
Publisher: Oxford University Press, USA
ISBN: 0198793456
Category : Medical
Languages : en
Pages : 449

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Book Description
Care of the Acutely Ill Adult equips all nurses with the knowledge and skills to care for deteriorating patients in the clinical environment. With its unique system-based approach, this key book emphasizes systematic assessment, careful monitoring, and timely escalation, and is essential reading for all nurses working in acute care settings.

Author: Deborah J. Grider
Publisher: American Medical Association Press
ISBN: 9781603592949
Category : Medical
Languages : en
Pages : 0

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Book Description
"This book helps readers understand the principles of medical record documentation and chart auditing. It introduces readers to principles of medical record documentation and how to conduct a medical record chart review in the physcian's or outpatient office"--Provided by publisher.