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 The Essentials of Clinical Documentation written by Maxine Jeffery and published by FriesenPress. This book was released on 2020-11-03 with total page 192 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book 2024 Essentials for Clinical Documentation Integrity written by and published by . This book was released on 2023-12 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Essentials for Clinical Documentation Integrity 2020 written by and published by . This book was released on 2020 with total page 318 pages. Available in PDF, EPUB and Kindle. Book excerpt:
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 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 416 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 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 Essential Clinical Procedures 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 35 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.
Download or read book The Clinical Documentation Sourcebook written by Donald E. Wiger and published by John Wiley & Sons. This book was released on 2010-02-02 with total page 338 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book Essentials of Clinical Supervision written by Jane M. Campbell and published by John Wiley & Sons. This book was released on 2005-11-11 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Essentials of Supervision presents, in the popular Essentials format, the key information students need to learn in a course on supervision. Utilizing pedagogical tools such as call-out boxes, Test Yourself questions, and case studies, the author provides step-by-step guidelines for effective planning, goal setting, and evaluation, along with tips for giving constructive feedback and applying coaching strategies to motivate supervisees. She also clearly explains how to manage paperwork and describes specialized techniques, such as using video in supervision. This informative text also includes a special section on ethics authored by a leading expert in the field.
Download or read book Clinical Documentation Improvement for Outpatient Care written by Pamela Carroll Hess and published by . This book was released on 2018 with total page 394 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book Drg Tools written by Maria Johar and published by Xlibris Us. This book was released on 2011-11-14 with total page 70 pages. Available in PDF, EPUB and Kindle. Book excerpt: the author will provide once available
Download or read book Medical Documentation written by Jerry G. Seare and published by Elsevier Health Sciences. This book was released on 1996 with total page 120 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Clinical Documentation written by Barbara Acello and published by Hcpro Incorporated. This book was released on 2007-01-01 with total page 333 pages. Available in PDF, EPUB and Kindle. Book excerpt: Clinical documentation can significantly affect a nursing home's survey results, reimbursement received, and most importantly, resident care. Yet, little formal training is given on how to complete this complicated, and often confusing, process. With so much at stake, it's critical that nurses have a resource they can turn to in order to help achieve accurate, comprehensive documentation for all residents.
Download or read book Clinical Documentation Specialist The Comprehensive Guide written by VIRUTI SHIVAN and published by Viruti Satyan Shivan. This book was released on with total page 232 pages. Available in PDF, EPUB and Kindle. Book excerpt: Dive into the essential world of clinical documentation with "Clinical Documentation Specialist - The Comprehensive Guide," a pivotal resource designed for healthcare professionals committed to excellence in patient care through meticulous record-keeping. This guide offers a deep dive into the principles of accurate and compliant medical documentation, highlighting its critical role in ensuring optimal patient outcomes and the seamless operation of healthcare systems. With an emphasis on practical strategies, real-world applications, and the latest compliance standards, this book serves as an invaluable tool for both aspiring and experienced clinical documentation specialists. By focusing on enhancing communication between healthcare providers and supporting the delivery of high-quality care, it addresses the challenges and complexities of modern medical documentation practices. Without relying on images or illustrations for clarity, the guide stands out for its comprehensive coverage and insightful analysis, making it a unique addition to the professional library of healthcare providers. It transcends basic instructional material by weaving in theoretical knowledge with actionable advice, empowering readers to navigate the nuanced landscape of healthcare documentation with confidence. The absence of visual elements is more than compensated for by the depth of knowledge and the engaging writing style, ensuring that readers are equipped with the knowledge and skills necessary to make a significant impact in their roles as guardians of patient information and care continuity.
Download or read book Clinical Documentation Specialist The Comprehensive Guide written by Viruti Shivan and published by . This book was released on 2024-04-25 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Mastering the Art of Medical Record Accuracy and Compliance for Enhanced Patient Care Dive into the essential world of clinical documentation with "Clinical Documentation Specialist - The Comprehensive Guide," a pivotal resource designed for healthcare professionals committed to excellence in patient care through meticulous record-keeping. This guide offers a deep dive into the principles of accurate and compliant medical documentation, highlighting its critical role in ensuring optimal patient outcomes and the seamless operation of healthcare systems. With an emphasis on practical strategies, real-world applications, and the latest compliance standards, this book serves as an invaluable tool for both aspiring and experienced clinical documentation specialists. By focusing on enhancing communication between healthcare providers and supporting the delivery of high-quality care, it addresses the challenges and complexities of modern medical documentation practices. Without relying on images or illustrations for clarity, the guide stands out for its comprehensive coverage and insightful analysis, making it a unique addition to the professional library of healthcare providers. It transcends basic instructional material by weaving in theoretical knowledge with actionable advice, empowering readers to navigate the nuanced landscape of healthcare documentation with confidence. The absence of visual elements is more than compensated for by the depth of knowledge and the engaging writing style, ensuring that readers are equipped with the knowledge and skills necessary to make a significant impact in their roles as guardians of patient information and care continuity.
Download or read book Clinical Documentation Improvement written by Pamela Carroll Hess and published by . This book was released on 2015 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
