Guide to Clinical Documentation

Author: Debra Sullivan
Publisher: F.A. Davis
ISBN: 9780803629974
Release Date: 2011-12-22
Genre: Medical

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.

Guide to Clinical Documentation

Author: Debra D. Sullivan
ISBN: 0803666624
Release Date: 2018-07
Genre: Medical

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. See what practitioners and students are saying online... Definitely worth the purchase. "This is a guide which will stay with you during your whole nursing do not rent you must buy it and think of it as a documentation bible!"--Barbie Great resource for NP/PA school. "Purchased this for my NP program. The book made writing SOAP notes and H&Ps very simple! Would recommend as a great resource"--Dr. Jon Love this! "Right down to it charting instructions and guidance. Even discusses codes and other factors of charting I had not taken into such deep account before. ... this book helped me understand how much more charting, other than SOAP's, must be completed for compliance standards. I feel this book is for just about everyone who is learning to chart as a reimbursable provider. --D. Conley

Documentation for Rehabilitation

Author: Lori Quinn
Publisher: Elsevier Health Sciences
ISBN: 9780323312332
Release Date: 2015-01-01
Genre: Communication in medicine

Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you've learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning. A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model - the one adopted by the APTA. Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings. Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies - especially important when insurance companies require evidence of functional progress in order to provide reimbursement. Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts. NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries. UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding. EXPANDED number of case examples covers an even broader range of clinical practice areas.

The Physician Advisor s Guide to Clinical Documentation Improvement

Author: Trey La Charite
Publisher: Hcpro, a Division of Blr
ISBN: 1615693475
Release Date: 2014-04-30
Genre: Medical

The Physician Advisor's Guide to Clinical Documentation Improvement Physician advisors are not just needed for case management anymore. ICD-10-CM/PCS and the changing landscape of healthcare reimbursement make their input invaluable in the realm of CDI and coding, too. This book will help your physician advisors quickly understand the vital role they play and how they can not only help improve healthcare reimbursement, but also reduce claims denials and improve the quality of care overall. This book will: * Provide job descriptions and sample roles and responsibilities for CDI physician advisors * Outline the importance of CDI efforts in specific relation to the needs and expectations of physicians * Highlight documentation improvement focus areas by Major Diagnostic Category * Review government initiatives and claims denial patterns, providing physician advisors concrete tools to sway physician documentation

The Counselor s Steps for Progress Notes

Author: Rhonda Sutton
Publisher: Createspace Independent Publishing Platform
ISBN: 1514643588
Release Date: 2015-06-21
Genre: Counseling

Dr. Rhonda Sutton's second edition of the straightforward guide to progress notes includes additional examples, information, documentation, and clinical language that expands on the utility and readability of the first book. Additional case studies provide examples of how to use the STEPs to format notes. New chapters include information on clinical language and documentation. This book covers everything about progress notes, from how to write them, to how to store them, and even what to do when someone requests to them. In addition, clinical terms and abbreviations are included as well as suggestions for other clinical documentation such as termination letters, privacy statements, and professional disclosure statements. Suited for all types of mental health clinicians, this book will help therapists improve upon their progress notes and other forms of clinical documentation.

Successful Collaboration in Healthcare

Author: Colleen M. Stukenberg
Publisher: CRC Press
ISBN: 9781439812938
Release Date: 2010-01-27
Genre: Business & Economics

This critically acclaimed work makes the case for collaboration and shows that it can be greatly enhanced with conscious understanding and systematic effort. As a healthcare specialist who has worn many hats from direct care giver to case manager to documentation specialist, Colleen Stukenberg is able to – Show how to build trust and communication and demonstrates specific opportunities where collaboration can make all the difference Identify ways that quality of care and financial factors overlap and the advantages that can be garnered through an understanding of this Explain how those in different roles view information through different types of knowledge and how an understanding of each perspective makes it easier to find the best source for important answers Discuss the education and ever-increasing role of the clinical documentation specialist who is often involved in all facets of a patient’s progress, from intake and admission right up through discharge. As the author points out, good healthcare is dependent on the right person performing the right role, which promotes excellent collaboration. And when people are allowed to function in their proper roles, job satisfaction increases, which in itself leads to better attitudes, which then leads to even deeper levels of collaboration and with it, the successful promotion of safe, quality care.


Author: Cherie Rebar
Publisher: F.A. Davis
ISBN: 9780803623361
Release Date: 2009-04-10
Genre: Medical

The perfect guide to charting! The popular Davis’s Notes format makes sure that you always have the information you need close at hand to ensure your documentation is not only complete and thorough, but also meets the highest ethical and legal standards. You’ll even find coverage of the nuances that are relevant to various specialties, including pediatric, OB/GYN, psychiatric, and outpatient nursing.

Documentation for Physician Assistants

Author: Debra D. Sullivan
Publisher: F A Davis Company
ISBN: 0803611412
Release Date: 2004
Genre: Medical

"GREAT! Specifically addresed PA concerns with appropriate information. Enjoyed the 'Practice' format and especially the pearls." -- Peggy D. McMillen, MPAS, PAC, PA Studies, East Carolina University, Greenville, North Carolina Numerous examples with hands-on, problem-based exercises

Clinical Documentation Improvement Specialist s Handbook

Author: Colleen Garry
Publisher: HC Pro, Inc.
ISBN: 9781601467751
Release Date: 2011-01-01
Genre: Medical

Improving documentation is no easy task CDI professionals have never had one easy-to-read, inclusive reference to help them implement a CDI program, understand the fundamentals of ICD-9-CM coding, query physicians, and encourage interdepartmental communication. In theory, physicians should document their entire thought process, including ruling conditions in and out. But it's not that simple, and in light of MS-DRGs, it requires significant physician education and retraining. You need a blueprint for success.. Your blueprint has arrived! At last, here is a guide for CDI specialists. The Clinical Documentation Improvement Specialist's Handbook is your essential partner for creating a CDI program, staffing your program, querying physicians, and understanding how documentation affects code selection and data quality As a CDI specialist you need answers now In light of Medicare Severity DRGs (MS-DRG), detailed documentation and accurate capture of complications and comorbidities (CCs) has made the CDI specialist's role more important and more demanding than ever. This handbook will enhance your ability to gather the right information the first time--and every time Author Colleen Garry, RN, BS, has compiled case studies that document best practices and reference several different CDI models so that you can select the one that's right for your hospital's CDI success. In addition, you'll be privy to an executive summary of HCPro's exclusive CDI survey that solicited more than 800 responses. Learn how other hospitals are handling CDI and choosing the model that works best for them. * work with physicians to obtain detailed, appropriate documentation * maintain compliance when performing physician queries * convey return on investment for a CDI program Customizable CD-ROM included Your copy of The Clinical Documentation Improvement Specialist's Handbook includes a CD-ROM loaded with all of the working tools you'll find in the book. Among them

Practical Guide to Clinical Computing Systems

Author: Thomas Payne
Publisher: Elsevier
ISBN: 0080557929
Release Date: 2011-09-02
Genre: Medical

The development of clinical computing systems is a rapidly growing priority area of health information technology, spurred in large measure by robust funding at the federal and state levels. It is widely recognized as one of the key components for reducing costs and improving the quality of care. At the same time as more and more hospitals and clinics are installing clinical computing systems, major issues related to design, operations, and infrastructure remain to be resolved. This book tackles these critical topics, including system selection, configuration, installation, user support, interface engines, and long-term operation. It also familiarizes the reader with regulatory requirements, budgetary issues, and other aspects of this new electronic age of healthcare delivery. It begins with an introduction to clinical computing and definition of key terminology. The next several chapters talk about system architecture and interface design, followed by detailed discussion of all aspects of operations. Attention is then given to the realities of leadership, planning, oversight, budgeting, and employee recruitment. This invaluable resource includes a special section that talks about career development for students and others interested in entering the field. *Provides a complete overview of practical aspects *Detailed guidance on the design and operation of clinical computing systems *Discusses how clinical computing systems relate to health care organization committees and organizational structure *Includes numerous real-life examples with expert insights on how to avoid pitfalls

The Clinical Documentation Improvement Specialist s Guide to ICD 10

Author: Jennifer Avery
Publisher: Hcpro, a Division of Blr
ISBN: 1615692002
Release Date: 2013-05-07
Genre: Medical

Now in its second edition, The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only guide to address ICD-10 from the CDI point of view. Written by CDI experts and ICD-10 Boot Camp instructors, it explains the ICD-10 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 a variety of conditions. The CDI Specialist's Guide to ICD-10, 2nd edition, not only outlines the changes coming in October 2014, it provides detailed information on how to assess staffing needs, training requirements, and implementation strategies. The authors-an ICD-10 certified coder and CDI specialist-collaborated to create a comprehensive selection of ICD-10 sample queries facilities can download and use to jumpstart ICD-10 documentation improvement efforts. Develop the expertise and comfort level you'll need to manage this important industry change and help your organization make a smooth transition. The Clinical Documentation Improvement Specialist's Guide to ICD- 10, 2nd ed. is part of the library of products and services from the Association of Clinical Documentation Improvement Specialists (ACDIS). ACDIS members are CDI professionals who share the latest tested tips, tools, and strategies to implement successful CDI programs and achieve professional growth. Member benefits include a quarterly journal, members-only Web site, quarterly networking conference calls, discounts on conferences, and more. WHAT'S NEW? Completely revised to accommodate changes in ICD-10 implementation dates Dozens of targeted ICD-10 physician queries Updated ICD-10 benchmarking reports BENEFITS Sample ICD-10 queries Specificity requirements and clinical indicators by disease type and body system Staff training and assessment tools