Guide to Clinical Documentation PDF Download

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: Richard W. Dehn
Publisher: Elsevier Health Sciences
ISBN: 0323624685
Category : Medical
Languages : en
Pages : 465

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Book Description
Provide safe and effective care to every patient with the fully revised 4th Edition of Essential Clinical Procedures. Written by experts in the field, this widely used reference shows you step by step how to perform more than 70 of the most common diagnostic and treatment-related procedures in today's primary care and specialist settings. You'll find clear, concise coverage of the skills you need to know, including new and advanced procedures and new procedure videos. - Covers patient preparation, the proper use of instruments, and potential dangers and complications involved in common procedures, as well as nonprocedural issues such as informed consent, standard precautions, patient education, and procedure documentation. - Includes new chapters on Point-of-Care Ultrasound and Ring Removal, as well as 34 new procedure videos. - Features significantly revised content on cryosurgery • injection techniques • arterial puncture • shoulder/finger subluxations • sterile technique • outpatient coding • casting and splinting • blood cultures • standard precautions • and more. - Contains more than 200 high-quality illustrations, including updated images of office pulmonary function testing and wound closure. - Uses a consistently formatted presentation to help you find information quickly. - Reflects the latest evidence-based protocols and national and international guidelines throughout. - Enhanced eBook version included with purchase. Your enhanced eBook allows you to access all of the text, figures, and references from the book on a variety of devices.

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: Maxine Jeffery
Publisher: FriesenPress
ISBN: 1525544047
Category : Medical
Languages : en
Pages : 192

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Book Description
This clinical manual is an ideal and standardized platform for preparing nursing students with the essential tools for documenting their nursing process. It teaches nursing students how to gather important data about each client in the clinical setting. Using this manual, the student nurse will be able to perform high quality documentation that is accurate and consistent in the client profile and laboratory and diagnostics, and their correlation and significance to the client’s diagnosis or diagnoses. This manual also covers the medication administration record, nursing interventions and rationales, and intake and output forms. The Situation Background Assessment Recommendation (SBAR) form and the use of a concept map complete the list of resources provided. Using this standardized documentation, the student will be able to: • Identify the primary patient data (past and present), diagnosis, and treatment plan. • Analyze patient data correlating and drawing conclusions relevant to patient outcome. • Document finding in a systematic manner. • Interpret diagnostic findings as relate to patient diagnosis This manual is intended for use in medical, surgical, and critical care clinical nursing courses.

Author: Laurie L. Prescott
Publisher:
ISBN: 9781556452833
Category : Clinical medicine
Languages : en
Pages : 0

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Book Description
Your new CDI specialist starts in a few weeks. They have the right background to do the job, but need orientation, training, and help understanding the core skills every new CDI needs. Don't spend time creating training materials from scratch. ACDIS' acclaimed CDI Boot Camp instructors have created The Clinical Documentation Improvement Specialist's Complete Training Guide to serve as a bridge between your new CDI specialists' first day on the job and their first effective steps reviewing records. The Clinical Documentation Improvement Specialist's Complete Training Guide is the perfect resource for CDI program managers to help new CDI professionals understand their roles and responsibilities. It will get your staff trained faster and working quicker. This training guide provides: An introduction for managers, with suggestions for training staff and guidance for manual use Sample training timelines Test-your-knowledge questions to reinforce key concepts Case study examples to illustrate essential CDI elements Documentation challenges associated with common diagnoses such as sepsis, pneumonia, and COPD Sample policies and procedures

Author: Pamela Carroll Hess
Publisher:
ISBN: 9781584265849
Category : Medical history taking
Languages : en
Pages : 394

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Book Description
Clinical Documentation Improvement for Outpatient Care: Design and Implementation is an all-inclusive guide to establishing and enhancing CDI programs for the outpatient amd professional fee setting.

Author: Pieter Kubben
Publisher: Springer
ISBN: 3319997130
Category : Medical
Languages : en
Pages : 219

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Book Description
This open access book comprehensively covers the fundamentals of clinical data science, focusing on data collection, modelling and clinical applications. Topics covered in the first section on data collection include: data sources, data at scale (big data), data stewardship (FAIR data) and related privacy concerns. Aspects of predictive modelling using techniques such as classification, regression or clustering, and prediction model validation will be covered in the second section. The third section covers aspects of (mobile) clinical decision support systems, operational excellence and value-based healthcare. Fundamentals of Clinical Data Science is an essential resource for healthcare professionals and IT consultants intending to develop and refine their skills in personalized medicine, using solutions based on large datasets from electronic health records or telemonitoring programmes. The book’s promise is “no math, no code”and will explain the topics in a style that is optimized for a healthcare audience.

Author: Cynthia Tang
Publisher:
ISBN: 9781733459433
Category :
Languages : en
Pages : 328

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Book Description

Author: Sylvia McKean
Publisher: McGraw Hill Professional
ISBN: 0071603905
Category : Medical
Languages : en
Pages : 2351

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Book Description
The definitive guide to the knowledge and skills necessary to practice Hospital Medicine Presented in full color and enhanced by more than 700 illustrations, this authoritative text provides a background in all the important clinical, organizational, and administrative areas now required for the practice of hospital medicine. The goal of the book is provide trainees, junior and senior clinicians, and other professionals with a comprehensive resource that they can use to improve care processes and performance in the hospitals that serve their communities. Each chapter opens with boxed Key Clinical Questions that are addressed in the text and hundreds of tables encapsulate important information. Case studies demonstrate how to apply the concepts covered in the text directly to the hospitalized patient. Principles and Practice of Hospital Medicine is divided into six parts: Systems of Care: Introduces key issues in Hospital Medicine, patient safety, quality improvement, leadership and practice management, professionalism and medical ethics, medical legal issues and risk management, teaching and development. Medical Consultation and Co-Management: Reviews core tenets of medical consultation, preoperative assessment and management of post-operative medical problems. Clinical Problem-Solving in Hospital Medicine: Introduces principles of evidence-based medicine, quality of evidence, interpretation of diagnostic tests, systemic reviews and meta-analysis, and knowledge translations to clinical practice. Approach to the Patient at the Bedside: Details the diagnosis, testing, and initial management of common complaints that may either precipitate admission or arise during hospitalization. Hospitalist Skills: Covers the interpretation of common “low tech” tests that are routinely accessible on admission, how to optimize the use of radiology services, and the standardization of the execution of procedures routinely performed by some hospitalists. Clinical Conditions: Reflects the expanding scope of Hospital Medicine by including sections of Emergency Medicine, Critical Care, Geriatrics, Neurology, Palliative Care, Pregnancy, Psychiatry and Addiction, and Wartime Medicine.

Author: Anthony Nkwuaku
Publisher: Createspace Independent Publishing Platform
ISBN: 9781984238788
Category :
Languages : en
Pages : 264

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Book Description
The book provides clear guides on how to perform the vital duties required in obtaining accurate, quality, complete, and specific documentation from the providers so as to reflect the quality of care, severity of illness and risk of mortality of admitted patients during their encounter to the hospital or inpatient rehab. The book is a "must have" for every CDIS or anyone involved in clinical documentation. The book has current ICD-10-CM/PCS update with pertinent information on the 2018 Official Coding Guidelines for Coding and Reporting, Coding Clinic advice, Pay for Performance, sample queries, various disease processes by MDCs, CDI strategy for success in inpatient rehab, rehab impairment group codes and categories, list of all the surgical and MS-DRGs, and much more. Remember, if it was not documented and documented accurately, it never happened.