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 Clinical Documentation Reference Guide First Edition written by AAPC and published by AAPC. This book was released on 2020-03-12 with total page 13 pages. Available in PDF, EPUB and Kindle. Book excerpt: It's not the quantity of clinical documentation that matters—it's the quality. Is your clinical documentation improvement (CDI) program identifying your outliers? Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Are you clear on how to fix your coding and documentation shortfalls? Providing the most complete and accurate coding of diagnoses and site-specific procedures will vastly improve your practice’s bottom line. Get the help you need with the Clinical Documentation Reference Guide. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complications and comorbidities, and CDI for EMRs. Learn the all-important steps to ensure your records capture what your physicians perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the practical and effective guidance in AAPC’s Clinical Documentation Reference Guide to triumph over your toughest documentation challenges. Prevent documentation deficiencies and keep your claims on track for optimal reimbursement: Understand the legal aspects of documentation Anticipate and avoid documentation trouble spots Keep compliance issues at bay Learn proactive measures to eliminate documentation problems Work the coding mantra—specificity, specificity, specificity Avoid common documentation errors identified by CERT and RACs Know the facts about EMR templates—and the pitfalls of auto-populate features Master documentation in the EMR with guidelines and tips Conquer CDI time-based coding for E/M The Clinical Documentation Reference Guide is approved for use during the CDEO® certification exam.

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 Nursing Documentation Handbook written by T. M. Marrelli and published by . This book was released on 2000 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Download or read book Documentation Manual for Writing SOAP Notes in Occupational Therapy written by Sherry Borcherding and published by Slack Incorporated. This book was released on 2005 with total page 236 pages. Available in PDF, EPUB and Kindle. Book excerpt: Manual focusing on documenting the occupational therapy process. Each skill is broken down into small steps and taught individually. Includes a template for writing problems, goals, and each section of the SOAP note. Also includes practice worksheets and detachable checklist and summary.

Download or read book The AMDP System written by Matthew R. Broome and published by Hogrefe Publishing GmbH. This book was released on 2018-03-21 with total page 288 pages. Available in PDF, EPUB and Kindle. Book excerpt: The 9th edition of this valuable tool for assessing and documenting psychopathology, now in English! Now in its 9th edition, the AMDP System is a widely used tool for documenting psychiatric symptoms in clinical and research projects. It is not only an essential part of many internal clinical documentation systems, but it is also a valuable instrument for training the identification of psychopathological symptoms. This new edition, now in English, involved the complete revision of the psychopathological and somatic symptoms, with particular attention to the elimination of ambiguities and inconsistencies, to the precision of definitions, to the exact differentiation of the self and other ratings, as well as to the user friendliness of the system. Taking account of developments in recent years in the description and rating of psychopathological symptoms, this latest edition of the AMDP System has been extended by an additional eleven psychopathological and three somatic symptoms and a new section on syndrome formation in the appendix. This clearly structured manual enables the standardized application of the system, making it an invaluable tool in the training of medicine and psychology students and an essential reference volume in the psychiatric field.

Download or read book The Clinical Documentation Improvement Specialist s Complete Training Guide written by Laurie L. Prescott and published by . This book was released on 2014-10-23 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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

Download or read book Writing Patient Client Notes written by Ginge Kettenbach and published by F.A. Davis. This book was released on 2016-05-11 with total page 295 pages. Available in PDF, EPUB and Kindle. Book excerpt: Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model.

Download or read book The Clinical Documentation Improvement Specialist s Handbook Second Edition written by Heather Taillon and published by HC Pro, Inc.. This book was released on 2011-01-21 with total page 171 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Clinical Documentation Improvement Specialist's Handbook, Second Edition Marion Kruse, MBA, RN; Heather Taillon, RHIA, CCDS Get the guidance you need to make your CDI program the best there is... The Clinical Documentation Improvement Specialist's Handbook, Second Edition, is an all-inclusive reference to help readers implement a comprehensive clinical documentation improvement (CDI) program with in-depth information on all the essential responsibilities of the CDI specialist. This edition helps CDI professionals incorporate the latest industry guidance and professional best practices to enhance their programs. Co-authors Heather Taillon, RHIA, and Marion Kruse, MBA, RN, combine their CDI and coding expertise to explain the intricacies of CDI program development and outline the structure of a comprehensive, multi-disciplinary program. In this edition you will learn how to: Adhere to the latest government and regulatory initiatives as they relate to documentation integrity Prepare for successful ICD-10 transition by analyzing your CDI program Step up physician buy-in with the improved education techniques Incorporate the latest physician query guidance from the American Health Information Management Association (AHIMA) Table of Contents Chapter 1: Building the CDI Program Chapter 2: CDI and the healthcare system Chapter 3: Application of coding guidelines Chapter 4: Compliant physician queries Chapter 5: Providing physician education Chapter 6: Monitoring the CDI program What's new in the Second Edition? Analysis of new industry guidance, including: AHIMA's "Managing an Effective Query Process" and "Guidance for Clinical Documentation Improvement Programs." CMS guidance from new IPPS regulations, MLN Matters articles, Quality Improvement Organizations, and the Recovery Audit Contractor (RAC) program, among others Strategies to help you incorporate the guidance into your CDI program. Tools to help you interpret MAC initiatives and RAC focus areas to enhance your CDI program and help prevent audit takebacks New sample queries, forms, tools, and industry survey data BONUS TOOLS! This book also includes bonus online tools you can put to use immediately! Sample query forms Sample job descriptions for CDI managers, and CDI specialists Sample evaluation form for CDI staff Sample pocket guide of common documentation standards

Download or read book Clinical Manual of Neuropsychiatry written by Stuart C. Yudofsky and published by American Psychiatric Pub. This book was released on 2012 with total page 450 pages. Available in PDF, EPUB and Kindle. Book excerpt: Clinical Manual of Neuropsychiatry offers clinicians the comprehensive, expert guidance that they require to deliver cutting-edge, effective, and compassionate patient care. Practical, comprehensive, and exhaustively researched, Clinical Manual of Neuropsychiatry is an indispensible resource for professionals.

Download or read book Nursing Documentation Made Incredibly Easy written by Kate Stout and published by Lippincott Williams & Wilkins. This book was released on 2018-06-05 with total page 487 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. Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy!®, 5th Edition. Packed with colorful images and clear-as-day guidance, this friendly reference guides you through meeting documentation requirements, working with electronic medical records systems, complying with legal requirements, following care planning guidelines, and more. Whether you are a nursing student or a new or experienced nurse, this on-the-spot study and clinical guide is your ticket to ensuring your charting is timely, accurate, and watertight. Let the experts walk you through up-to-date best practices for nursing documentation, with: NEW and updated, fully illustrated content in quick-read, bulleted format NEWdiscussion of the necessary documentation process outside of charting—informed consent, advanced directives, medication reconciliation Easy-to-retain guidance on using the electronic medical records / electronic health records (EMR/EHR) documentation systems, and required charting and documentation practices Easy-to-read, easy-to-remember content that provides helpful charting examples demonstrating what to document in different patient situations, while addressing the different styles of charting Outlines the Do's and Don’ts of charting – a common sense approach that addresses a wide range of topics, including: Documentation and the nursing process—assessment, nursing diagnosis, planning care/outcomes, implementation, evaluation Documenting the patient’s health history and physical examination The Joint Commission standards for assessment Patient rights and safety Care plan guidelines Enhancing documentation Avoiding legal problems Documenting procedures Documentation practices in a variety of settings—acute care, home healthcare, and long-term care Documenting special situations—release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behavior Special features include: Just the facts – a quick summary of each chapter’s content Advice from the experts – seasoned input on vital charting skills, such as interviewing the patient, writing outcome standards, creating top-notch care plans “Nurse Joy” and “Jake” – expert insights on the nursing process and problem-solving That’s a wrap! – a review of the topics covered in that chapter About the Clinical Editor Kate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport, North Carolina.

Download or read book Manual for Clinical Trials Nursing written by Angela D. Klimaszewski and published by . This book was released on 2015 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: The brand-new third edition of the Manual for Clinical Trials Nursing provides a more comprehensive guide for clinical trials nurses of all levels of experience and practice settings. With expanded content and reorganized chapters to facilitate location of desired content, the book covers topics ranging from history and fundamental information through protocol development and financial factors, recruitment and retention, clinical trial participants, and genetics and genomics to correlative trials, quality assurance, professional development, and international research efforts. Since clinical trials research is dynamic, the new edition directs the reader to pertinent websites where the most current information is available. -- Provided by publisher.

Download or read book The Ophthalmic Scribe Manual written by Parker J Williams and published by . This book was released on 2019-04-29 with total page 162 pages. Available in PDF, EPUB and Kindle. Book excerpt: Product Description The Ophthalmic Scribe Manual is the ultimate how-to manual for learning to scribe in ophthalmology. If you're interested in learning more about scribing in retina, cornea, comprehensive, glaucoma, or oculoplastics, this manual has you covered. Inside, you will find over 100 full-color figures and tables illustrating the most important concepts, Anatomy & Physiology, organized high-yield abbreviations, must know medications, must know imaging modalities, and high-yield specialty-specific pathology. About the Author After graduating with a Bachelor of Science in Biology from the University of North Carolina at Chapel Hill and prior to enrolling in medical school, my job search brought me back home to Atlanta where I accepted a position as an Ophthalmic Medical Scribe. I had no prior experience as a scribe or in the healthcare field, but I knew that quickly improving my understanding of ophthalmology would be essential for my success. I searched the web to obtain every piece of relevant ophthalmology information that I could find, and I spent hours experimenting with the functionalities of the eye clinic's electronic medical record to better prepare myself for my new role. However, I found that it took a significant amount of time and effort to sift through the excessive online information before I was able to hone in on the relevant material. Due to the lack of designated ophthalmic medical scribe training resources and the vast amount of irrelevant information online, I decided that the creation of The Ophthalmic Scribe Manual was warranted. With over 3 years of scribing experience and over 20,000 patient encounters, as well as having published a variety of first author case reports and review articles in prominent ophthalmic medical journals, I am confident that my experiences will offer an immediate benefit to those seeking to excel in this rewarding profession. Review "Very well-written! This looks terrific and will be great for widespread use particularly in training programs, especially with the growing need for trained ophthalmic personnel."

Download or read book A Clinical Trials Manual From The Duke Clinical Research Institute written by Margaret Liu and published by John Wiley & Sons. This book was released on 2011-08-24 with total page 381 pages. Available in PDF, EPUB and Kindle. Book excerpt: "The publication of the second edition of this manual comes at an important juncture in the history of clinical research. As advances in information technology make it possible to link individuals and groups in diverse locations in jointly seeking the answers to pressing global health problems, it is critically important to remain vigilant about moral and ethical safeguards for every patient enrolled in a trial. Those who study this manual will be well aware of how to ensure patient safety along with fiscal responsibility, trial efficiency, and research integrity." —Robert Harrington, Professor of Medicine, Director, Duke Clinical Research Institute, Durham, North Carolina, USA The Duke Clinical Research Institute (DCRI) is one of the world's leading academic clinical research organizations; its mission is to develop and share knowledge that improves the care of patients around the world through innovative clinical research. This concise handbook provides a practical "nuts and bolts" approach to the process of conducting clinical trials, identifying methods and techniques that can be replicated at other institutions and medical practices. Designed for investigators, research coordinators, CRO personnel, students, and others who have a desire to learn about clinical trials, this manual begins with an overview of the historical framework of clinical research, and leads the reader through a discussion of safety concerns and resulting regulations. Topics include Good Clinical Practice, informed consent, management of subject safety and data, as well as monitoring and reporting adverse events. Updated to reflect recent regulatory and clinical developments, the manual reviews the conduct of clinical trials research in an increasingly global context. This new edition has been further expanded to include: In-depth information on conducting clinical trials of medical devices and biologics The role and responsibilities of Institutional Review Boards, and Recent developments regarding subject privacy concerns and regulations. Ethical documents such as the Belmont Report and the Declaration of Helsinki are reviewed in relation to all aspects of clinical research, with a discussion of how researchers should apply the principles outlined in these important documents. This graphically appealing and eminently readable manual also provides sample forms and worksheets to facilitate data management and regulatory record retention; these can be modified and adapted for use at investigative sites.

Download or read book Manual of Psychiatric Care for the Medically Ill written by Antoinette Ambrosino Wyszynski and published by American Psychiatric Pub. This book was released on 2008-05-20 with total page 416 pages. Available in PDF, EPUB and Kindle. Book excerpt: Manual of Psychiatric Care for the Medically Ill delivers a practical approach to accurate psychiatric diagnosis and treatment in the medical-surgical setting. The editors have updated the literature reviews of their widely used 1996 American Psychiatric Publishing publication A Case Approach to Medical-Psychiatric Practice and have added easy-to-use summaries, Web resources, checklists, flowcharts, and worksheets-all designed to facilitate and teach the process of psychiatric consultation. The appended study guide makes this book even more valuable as an educational tool. Intended as a companion guide to comprehensive textbooks in psychosomatic medicine, this concise volume combines medication updates with "how-to" strategies for the psychiatric treatment of patients with cardiovascular, hepatic, renal, and pulmonary disease; gastrointestinal symptoms; delirium; HIV; hepatitis C; steroid-induced psychiatric syndromes; and organ transplantation. A special feature is the comprehensive chapter on the treatment of psychiatric illness in pregnancy. Each chapter summarizes the literature, emphasizing diagnostic and treatment considerations for patients with psychiatric symptoms and medical illnesses. Representing the work of 24 contributors, this useful, highly informative volume features Checklists, flowcharts, and worksheets that can be photocopied and brought to the patient's bedside for use during the clinical consultation. These templates help focus the information-gathering process, organize the data, and generate important documentation. Standardized assessment instruments and questionnaires, such as the Michigan Alcohol Screening Test, Delirium Rating Scale-Revised-98, and HIV Dementia Scale, which assist in consultation and evaluation. Summaries and charts of differential diagnoses to assist psychiatric consultation to medical patients, including Web addresses to access the latest information on a particular condition or treatment. A study guide in case-question-answer format for selected chapters. This volume also includes a "how-to" chapter on assessing decisional capacity, complete with a worksheet for gathering information and documenting informed consent. It also features practical reviews of psychotherapeutic issues, such as a primer for what to do when patients ask about spiritual issues. Concluding chapters present short, practical guides on addressing general psychological issues occurring in medical patients. This proven manual -- already being used to teach residents the core curriculum in Consultation-Liaison Psychiatry and On-Call Preparedness at Bellevue Hospital in New York City -- will be welcomed by general psychiatrists, consultation-liaison and psychosomatic medicine fellows, residents, and medical students everywhere.

Download or read book The Book of Style for Medical Transcription written by Lea M. Sims and published by . This book was released on 2008-06 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Download or read book ICD 10 CM Official Guidelines for Coding and Reporting FY 2021 October 1 2020 September 30 2021 written by Department Of Health And Human Services and published by Lulu.com. This book was released on 2020-09-06 with total page 128 pages. Available in PDF, EPUB and Kindle. Book excerpt: These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.