Download or read book Guide to Clinical Documentation written by Debra Sullivan and published by F.A. Davis. This book was released on 2011-12-22 with total page 301 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book Guide to Clinical Documentation written by Debra D Sullivan and published by F.A. Davis. This book was released on 2018-07-25 with total page 417 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book Targeted Regulatory Writing Techniques Clinical Documents for Drugs and Biologics written by Linda Fossati Wood and published by Springer Science & Business Media. This book was released on 2009-01-05 with total page 235 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book describes the authors’ standard or ‘best’ practices used in writing regul- ed clinical documents for the drug and biologics industry. The fundamental premise of this book is that the end (documents submitted to a health authority) is dep- dent on the beginning (the planning and strategy that go into organizing written documentation). Each regulatory document inherently exists within a constellation of related documents. This book attempts to show the relationships between and among these documents and suggests strategies for organizing and writing these documents to maximize ef?ciency while developing clear and concise text. At all times, and irrespective of applicable laws and guidelines, good communication skills and a sense of balance are essential to adequately, accurately, and clearly describe a product’s characteristics. At no time should the reader perceive these suggestions to be the only viable solution to writing regulatory documents nor should the reader expect that these suggestions guarantee product success. The audience for this book is the novice medical writer, or those who would like to explore or enhance regulatory-writing skills. We assume the reader will have a basic understanding of written communication, but little experience in applying this skill to the task of regulatory writing. Extensive knowledge of science, clinical me- cine, mathematics, or regulatory affairs law is not required to use the best practices described in this book.
Download or read book Manual of Inpatient Psychiatry written by Michael I. Casher and published by Cambridge University Press. This book was released on 2020-03-26 with total page 239 pages. Available in PDF, EPUB and Kindle. Book excerpt: Explores the range of diagnoses found on inpatient psychiatric units providing practical advice in an accessible format for managing patients.
Download or read book The Clinical Documentation Improvement Specialist s Guide to ICD 10 written by Glenn Krauss and published by HC Pro, Inc.. This book was released on 2011-03 with total page 163 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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
Download or read book Social Work Documentation written by Nancy Sidell and published by N A S W Press. This book was released on 2011 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Social work practitioners spend a lot of time documenting services they provide, but many are ill-prepared for this practice responsibility. In Social Work Documentation: A Guide to Strengthening Your Case Recording, Nancy Sidell has written the perfect, practical, how-to book on developing effective documentation. Regardless of the practice setting, clinical specialty, and documentation format, this book will help to build better recording skills. In her book, Social Work Documentation: A Guide to Strengthening Your Case Recording, Dr. Sidell provides a clear, concise, and thorough justification of why documentation is important, the different styles used to record client information, and an array of valuable case exercises to work through. Particularly useful is the inclusion of current and relevant examples of documentation that represent a range of practice fields at all levels of social work intervention to include: micro, mezzo, and macro. Woven throughout the workbook are ethical, legal, and supervisory situations that occur in practice that require the reader to critically think about how they would respond. This book is suitable and highly recommended for undergraduate and graduate education, agency trainings, and continuing education courses.
Download or read book Nursing Know how written by and published by Lippincott Williams & Wilkins. This book was released on 2009 with total page 424 pages. Available in PDF, EPUB and Kindle. Book excerpt: Provides information on documentation issues, including electronic medical records, legal and ethical implications, and documentation in acute cases, along with a variety of charting examples.
Download or read book Essential Clinical Procedures E Book written by Richard W. Dehn and published by Elsevier Health Sciences. This book was released on 2020-01-10 with total page 465 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book Writing Skills for Veterinarians written by Ryane E. Englar and published by 5m Books Ltd. This book was released on 2019-02-05 with total page 268 pages. Available in PDF, EPUB and Kindle. Book excerpt: Communicating ideas in veterinary medicine is a fundamental part of continuing veterinary research and building a career as a clinician. The purpose of this book is to help increasing efficiency and effectiveness in writing professional documents, e.g. writing a concise yet thorough discharge statement to avoid repeated client call-backs to clarify medical recommendations. The book also aims at improving the reader’s confidence in writing skills through guided and well-thought out “homework” or practice exercises. Useful for both veterinary students and practising vets, Writing Skills for Veterinarians addresses how to develop and hone veterinary medical and scientific writing techniques. The basics of veterinary writing and why it matters are covered before concentrating on specific written models expected of vets – creating medical documents, client and colleague communications, report writing, journal articles and research papers and presentations. At the end of the book is a resource-bank of additional exercises relating to each type of document. 5m Books
Download or read book Tabbner s Nursing Care E Book written by Gabby Koutoukidis and published by Elsevier Health Sciences. This book was released on 2012-10-01 with total page 2426 pages. Available in PDF, EPUB and Kindle. Book excerpt: A vital member of the health care team, the contemporary enrolled nurse faces increasing challenges and an increasing level of responsibility. Written specifically for Australian and New Zealand enrolled nurse students, this long awaited new edition reflects the changes and challenges in contemporary enrolled nurse practice as well as the additions and modifications that are occurring in nursing curricula. Tabbner’s Nursing Care: Theory and Practice 5th edition has been written, reviewed and edited by the people who educate the enrolled nurse and continues to provide enrolled nurse students with the most comprehensive resource available.
Download or read book Diagnostic Report Writing In Speech Language Pathology written by Steven Blaustein and published by Taylor & Francis. This book was released on 2024-06-01 with total page 185 pages. Available in PDF, EPUB and Kindle. Book excerpt: Designed to improve the report writing skills of speech-language pathology students, communication sciences and disorders students, Clinical Fellows, and professionals alike, Diagnostic Report Writing in Speech-Language Pathology: A Guide to Effective Communication is a one-of-a-kind text entirely dedicated to the production of an effective diagnostic speech and language evaluation. In today’s academic and health care climate, accurate and clear documentation has never been more important. Diagnostic Report Writing in Speech-Language Pathology seeks to demystify and simplify the challenges many students and clinicians face while learning to write speech and language evaluations by combining the science and art of assessment with an effective presentation. Dr. Steven H. Blaustein uses his more than 50 years of experience as a clinician, consultant, and professor to logically guide the reader through the necessary steps involved in the documentation of a speech and language evaluation. From discussing the initial reason for the referral and case history to the final summary, impressions, and recommendations, each step of the writing process is clearly explained. Topics included in Diagnostic Report Writing in Speech-Language Pathology: Speech sound production Oral peripheral examinations Issues of law, fairness, and ethics Critical information for the approval of services and third-party reimbursement Common report writing errors to avoid Images and tables to illustrate the process of documenting a speech and language evaluation There is no one-size-fits-all template for documenting an evaluation. Diagnostic Report Writing in Speech-Language Pathology: A Guide to Effective Communication provides the reader with the skills and knowledge necessary to compile an effective professional report that meets the needs of patients, clients, students, and outside stakeholders.
Download or read book Clinical Documentation Improvement written by Rn Phn Nkwuaku, Msn Cphq and published by Createspace Independent Publishing Platform. This book was released on 2015-12-17 with total page 246 pages. Available in PDF, EPUB and Kindle. Book excerpt: Clinical Documentation Improvement (CDI) Made Easy is a great resource and reference that every Clinical Documentation Improvement Specialist/Professional (CDIS/CDIP), coder, physician champion/advisor, and others involved in the CDI must have. The book is a compendium of sound clinical knowledge and experience, clinical documentation expertise, and quality, which will help the CDIS/CDIP and others maximize their potentials in performing their core duties. Whether you are a new CDIS trying to learn CDI or an experienced CDIS hoping to stay current with CDI world, or involved in the CDI, this book will be very valuable to you. Remember, accurate and quality documentation is a reflection of great patient care. "If it wasn't documented, and documented accurately, it never happened." This book clearly explained various query opportunities by Major Disease Classifications (MDCs) with some sample queries. It defines and analyses different disease processes, creates CDIS awareness and what to look for under various MDCs, ICD-10-CM/PCS, explained current CMS Pay for Performance (P4P), and the CDI responsibility under P4P, explained some pertinent coding guidelines, 2016 Official Coding Guidelines for Coding and Reporting, AHIMA/ACDIS practice brief for queries and compliance, and much more. I have no doubt in my mind that this book is a concise but a comprehensive tool and reference that anyone involved in CDI should always have at his/her side. The Author Anthony O Nkwuaku, RN, PHN, MSN, CPHQ, CCDS is very knowledgeable and experienced as a clinician, clinical instructor, and Clinical Documentation Improvement Specialist.
Download or read book DSM 5 in Action written by Sophia F. Dziegielewski and published by John Wiley & Sons. This book was released on 2014-09-24 with total page 613 pages. Available in PDF, EPUB and Kindle. Book excerpt: Full exploitation of the DSM-5 allows for more comprehensive care By demystifying the DSM-5, author Sophia Dziegielewski goes beyond the traditional diagnostic assessment and suggests both treatment plans and practice strategy. She covers the changes in criteria to the DSM-5 and what those changes mean for mental health professionals. This resource has been updated to include: New and updated treatment plans All treatment plans, interventions strategies, applications, and practice implications are evidence based Instructions on doing diagnostic assessments and differential diagnosis using the DSM-5 Changes to coding and billing using the DSM-5 and ICD-10 The book includes robust tools for students, instructors, and new graduates seeking licensure. DSM-5 in Action makes the DSM-5 accessible to all practitioners, allowing for more accurate, comprehensive care.
Download or read book Academic Writing and Referencing for your Nursing Degree written by Jane Bottomley and published by Critical Publishing. This book was released on 2017-07-26 with total page 177 pages. Available in PDF, EPUB and Kindle. Book excerpt: Invaluable jargon-free guide for anyone doing a nursing degree, providing study support and helping you to improve your academic writing and referencing skills. Academic Writing and Referencing for your Nursing Degree provides you with a sound knowledge and understanding of: what constitutes good academic writing in nursing a range of strategies for writing successful essays and reports the importance of clarity and coherence in your writing about nursing how to improve your academic style, grammar and punctuation, and formatting and presentation referencing conventions in the field of nursing, and of how to avoid plagiarism. If you are embarking on a university nursing degree, the books in our Critical Study Skills for Nursing series will help you acquire and develop the knowledge, skills and strategies you need to achieve your goals. They provide support in all areas important for university study, including institutional and disciplinary policy and practice, self-management, and research and communication. Tasks and activities are designed to foster aspects of learning which are valued in higher education, including learner autonomy and critical thinking, and to guide you towards reflective practice in your study and work life.
Download or read book The Health Care Handbook written by Elisabeth T. Askin and published by Lippincott Williams & Wilkins. This book was released on 2022-11-21 with total page 191 pages. Available in PDF, EPUB and Kindle. Book excerpt: Described in the New York Times as “an astonishingly clear ‘user’s manual’ that explains our health care system and the policies that will change it,” The Health Care Handbook, by Drs. Elisabeth Askin and Nathan Moore, offers a practical, neutral, and readable overview of the U.S. health care system in a compact, convenient format. The fully revised third edition provides concise coverage on health care delivery, insurance and economics, policy, and reform—all critical components of the system in which health care professionals work. Written in a conversational and accessible tone, this popular, highly regarded handbook serves as a “one stop shop” for essential facts, systems, concepts, and analysis of the U.S. health care system, providing the tools you need to confidently evaluate current health care policy and controversies.
Download or read book Fundamentals Perspectives on the Art and Science of Canadian Nursing written by david Gregory and published by Lippincott Williams & Wilkins. This book was released on 2019-01-03 with total page 2480 pages. Available in PDF, EPUB and Kindle. Book excerpt: Publisher's Note: Products purchased from 3rd Party sellers are not guaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product. Master the unique, multi-faceted role of the Canadian nurse. Confidently embark on a lifelong learning journey and prepare for the daily realities of Canadian nursing practice this with comprehensive, Canadian-focused text. Developed specifically for your needs by talented Canadian students, practicing nurses, scholars, and educators, Fundamentals: Perspectives on the Art and Science of Canadian Nursing, 2nd Edition, delivers an integrated understanding of nursing fundamentals through a continuum that guides you from one chapter to the next and from learning to understanding. New! Inter-Professional Practice helps you achieve positive patient outcomes through effective collaboration with the healthcare team. New! Diversity Considerations alert you to important patient care considerations related to culture, sexuality, gender, economics, visible minorities, and religious beliefs. New! NCLEX®-style questions at the end of each chapter test your retention and ready you for success on your exams. Revised! Skills chapters familiarize you with a wide variety of advanced skills to broaden your clinical capabilities. Enhanced focus on LGBTQ-related considerations, demographic shifts in Canadian society, end-of-life/palliative care, substance abuse crises, and refugee communities helps you ensure confident care across diverse Canadian populations. Case Studies place chapter content in a realistic context for the most practical understanding. Think Boxes encourage critical thinking and challenge you to apply your knowledge to different situations. Through the Eyes features familiarize you with patients’ perspectives to help you provide thoughtful and effective care interventions. Research equips you with the latest and most relevant Canadian healthcare findings based on clinical evidence. Critical Thinking Case Scenarios strengthen your clinical focus and critical thinking through real-life situations.
Download or read book Complete Guide to Documentation written by Lippincott Williams & Wilkins and published by Lippincott Williams & Wilkins. This book was released on 2008 with total page 454 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
