Author : Debra Sullivan
Publisher : F.A. Davis
Page : 301 pages
File Size : 46,74 MB
Release : 2011-12-22
Category : Medical
ISBN : 0803629974
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.
Author : Deborah J. Grider
Publisher : American Medical Association Press
Page : 0 pages
File Size : 35,55 MB
Release : 2011
Category : Medical
ISBN : 9781603592949
"This book helps readers understand the principles of medical record documentation and chart auditing. It introduces readers to principles of medical record documentation and how to conduct a medical record chart review in the physcian's or outpatient office"--Provided by publisher.
Author : Agency for Healthcare Research and Quality/AHRQ
Publisher : Government Printing Office
Page : 385 pages
File Size : 50,63 MB
Release : 2014-04-01
Category : Medical
ISBN : 1587634333
This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.
Author : Barbara Odom-Wesley
Publisher :
Page : 538 pages
File Size : 37,26 MB
Release : 2008-08
Category : Medical informatics
ISBN : 9781584261834
Author : Fiona Creed
Publisher : Oxford University Press
Page : 481 pages
File Size : 32,69 MB
Release : 2020-10-08
Category : Medical
ISBN : 0192527088
This key textbook equips all nurses with the knowledge and skills required to care for the deteriorating patient in the clinical environment. The book emphasises the importance of systematic assessment, interpretation of clinical signs of deterioration, and the need to escalate the patient in a timely manner. Using a unique system-based approach, each chapter contains structured learning outcomes and concludes with a competence-based skills assessment to perfect the reader's practice skills. These skills are recommended as essential for every nurse in an acute area and key to successful practice. Restructured for ease of use, this new edition has been fully updated to match current guidelines, with new chapters on pain management and the ethics and ceilings of treatment. Written by senior nurses, this key textbook uses real life case studies to link knowledge to practice and is essential reading for all nurses working in acute care settings and undertaking study in the field.
Author : Lippincott Williams & Wilkins
Publisher : Lippincott Williams & Wilkins
Page : 454 pages
File Size : 21,76 MB
Release : 2008
Category : Medical
ISBN : 9781582555560
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.
Author : Deborah J. Grider
Publisher : American Medical Association Press
Page : 388 pages
File Size : 50,20 MB
Release : 2002
Category : Business & Economics
ISBN :
The quality of coding is an important factor in determining the financial health of a practice. When problems occur they must be solved quickly. But before they can be solved, they must be found. Medical Record Chart Analyzer includes medical record documentation with a systematic guide to the medical record review process for the physician's or outpatient office. Learning objectives are included at the beginning of most chapters to overview chapter content and help measure progress. Medical chart review and coding tips are located throughout the book. The application exercises allow the reader to master each topic one chapter at a time. Also included is a final examination to test documentation and auditing skills. By the end of the book, the reader will be able to conduct reviews independently. Authored by Deborah J. Grider, CPC, CPC-H, CCS-P, CCP, an experienced professional in the fields of reimbursement, procedural and diagnostic coding, medical practice management and compliance. Readers can earn up to 10 CEU credits from AAPC.
Author : AAPC
Publisher : AAPC
Page : 13 pages
File Size : 23,21 MB
Release : 2020-03-12
Category : Medical
ISBN : 1626889791
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.
Author : Sylvia McKean
Publisher : McGraw Hill Professional
Page : 2351 pages
File Size : 32,20 MB
Release : 2011-12-30
Category : Medical
ISBN : 0071603905
The definitive guide to the knowledge and skills necessary to practice Hospital Medicine Presented in full color and enhanced by more than 700 illustrations, this authoritative text provides a background in all the important clinical, organizational, and administrative areas now required for the practice of hospital medicine. The goal of the book is provide trainees, junior and senior clinicians, and other professionals with a comprehensive resource that they can use to improve care processes and performance in the hospitals that serve their communities. Each chapter opens with boxed Key Clinical Questions that are addressed in the text and hundreds of tables encapsulate important information. Case studies demonstrate how to apply the concepts covered in the text directly to the hospitalized patient. Principles and Practice of Hospital Medicine is divided into six parts: Systems of Care: Introduces key issues in Hospital Medicine, patient safety, quality improvement, leadership and practice management, professionalism and medical ethics, medical legal issues and risk management, teaching and development. Medical Consultation and Co-Management: Reviews core tenets of medical consultation, preoperative assessment and management of post-operative medical problems. Clinical Problem-Solving in Hospital Medicine: Introduces principles of evidence-based medicine, quality of evidence, interpretation of diagnostic tests, systemic reviews and meta-analysis, and knowledge translations to clinical practice. Approach to the Patient at the Bedside: Details the diagnosis, testing, and initial management of common complaints that may either precipitate admission or arise during hospitalization. Hospitalist Skills: Covers the interpretation of common “low tech” tests that are routinely accessible on admission, how to optimize the use of radiology services, and the standardization of the execution of procedures routinely performed by some hospitalists. Clinical Conditions: Reflects the expanding scope of Hospital Medicine by including sections of Emergency Medicine, Critical Care, Geriatrics, Neurology, Palliative Care, Pregnancy, Psychiatry and Addiction, and Wartime Medicine.
Author : Gavriel Salvendy
Publisher : John Wiley & Sons
Page : 1754 pages
File Size : 42,31 MB
Release : 2012-05-24
Category : Technology & Engineering
ISBN : 1118129083
The fourth edition of the Handbook of Human Factors and Ergonomics has been completely revised and updated. This includes all existing third edition chapters plus new chapters written to cover new areas. These include the following subjects: Managing low-back disorder risk in the workplace Online interactivity Neuroergonomics Office ergonomics Social networking HF&E in motor vehicle transportation User requirements Human factors and ergonomics in aviation Human factors in ambient intelligent environments As with the earlier editions, the main purpose of this handbook is to serve the needs of the human factors and ergonomics researchers, practitioners, and graduate students. Each chapter has a strong theory and scientific base, but is heavily focused on real world applications. As such, a significant number of case studies, examples, figures, and tables are included to aid in the understanding and application of the material covered.
