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: Christine Sullivan
Publisher: F A Davis Company
ISBN: 0803625839
Release Date: 2011-12
Genre: Medical

Rev. ed. of: Documentation for physician assistants / Debra D. Sullivan, Lynnette J. Mattingly. c2004.

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

Documentation for Rehabilitation

Author: Lori Quinn
Publisher: Elsevier Health Sciences
ISBN: 9780323312332
Release Date: 2015-12-11
Genre:

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.

Ota s Guide to Documentation

Author: Marie Morreale
Publisher: Slack
ISBN: 1630912964
Release Date: 2017
Genre:

Now updated to itsFourth Edition, The OTA's Guide to Documentation: Writing SOAP Notescontains the step-by-step instruction needed to learn occupational therapy documentation and meet the legal, ethical, and professional documentation standards required for clinical practice and reimbursement of services. Written in an easy-to-read- format, this Fourth Edition by Marie J. Morreale and Sherry Borcherding will aid occupational therapy assistants (OTAs) in learning the purpose and standards of documentation throughout all stages of the occupational therapy process and different areas of clinical practice. Essentials of documentation, reimbursement, and best practice are reflected in the many examples presented throughout The OTA's Guide to Documentation: Writing SOAP Notes, Fourth Edition, including a practical method for goal writing (COAST), which is explained thoroughly. Worksheets and learning activities provide the reader with multiple opportunities to practice observation skills and clinical reasoning, learn documentation methods, create occupation-based goals, and develop a repertoire of professional language. Answers to all the worksheets are provided to enable independent study, and a detachable summary sheet can be pulled out and carried to clinical sites as a reminder of the necessary contents for a SOAP note. Templates are provided to assist beginning OTA students in formatting occupation-based SOAP notes and the task of documentation is broken down into smaller units to make learning easier. Other formats and methods of recording client care are also explained, such as the use of electronic health records and narrative notes. This text also presents an overview of the initial evaluation process delineating the roles of the OT and OTA and guidelines for implementing appropriate interventions. New in the Fourth Edition: Incorporation of the Occupational Therapy Practice Framework: Domain and Process, Third Edition and other updated American Occupational Therapy Association documents Additional information on electronic health records and more examples from emerging niches of occupational therapy practice Updated information to meet Medicare Part B and other third party payer requirements Additional lists of professional language and abbreviations Extra tips for avoiding common documentation mistakes New tables, worksheets, and learning activities Instructors in educational settings can visit www.efacultylounge.com for additional material to be used in the classroom. Updated with new features and information,The OTA's Guide to Documentation: Writing SOAP Notes, Fourth Edition offers both the instruction and multiple opportunities to practice documentation, providing OTAs with the necessary skills to record client care effectively. Bonus Video Content: When you purchase a new copy of The OTA's Guide to Documentation: Writing SOAP Notes, Fourth Edition, you will receive access to scenario-based videos to practice the documentation process.

Nurses Guide to Clinical Procedures

Author: Jean Smith-Temple
Publisher: Lippincott Williams & Wilkins
ISBN: 0781753791
Release Date: 2006
Genre: Medical

The revised Fifth Edition of this pocket guide provides step-by-step instructions for over 200 common nursing procedures. This edition has over 15 new procedures, a reorganized Table of Contents that helps readers find information quickly, and a new art program with new and updated illustrations. Each procedure is organized according to the nursing process, including assessment, sample diagnoses, planning, desired outcomes, implementation, evaluation, and documentation. Planning sections emphasize individual client needs and include pediatric, geriatric, home health, cultural, end-of-life, and delegation considerations. Implementation sections present specific steps and rationales in two-column format. Icons highlight cultural considerations and cost-cutting tips. This edition is also available for PDAs. See Media listing for details.

Clinical Guide to Positional Release Therapy

Author: Speicher, Timothy E.
Publisher: Human Kinetics
ISBN: 9781450496247
Release Date: 2016-02-23
Genre: Medical

Clinical Guide to Positional Release Therapy With Web Resource is an invaluable resource for those who desire to learn, practice, and perfect the art of positional release therapy (PRT) to gently treat patients of all ages who have acute and chronic somatic dysfunction.

Documentation for Rehabilitation

Author: Lori Quinn
Publisher: Saunders
ISBN: 0323312381
Release Date: 2015-11-01
Genre:

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.