Guide To Clinical Documentation
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Guide To Clinical Documentation
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Author : Debra D Sullivan
language : en
Publisher: F.A. Davis
Release Date : 2018-07-25
Guide To Clinical Documentation written by Debra D Sullivan and has been published by F.A. Davis this book supported file pdf, txt, epub, kindle and other format this book has been release on 2018-07-25 with Medical categories.
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.
Clinical Documentation Reference Guide First Edition
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Author : AAPC
language : en
Publisher: AAPC
Release Date : 2020-03-12
Clinical Documentation Reference Guide First Edition written by AAPC and has been published by AAPC this book supported file pdf, txt, epub, kindle and other format this book has been release on 2020-03-12 with Medical categories.
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.
A Practical Guide To Clinical Documentation In Behavioral Health Care
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Author : Joint Commission on Accreditation of Healthcare Organizations
language : en
Publisher:
Release Date : 1997-01-01
A Practical Guide To Clinical Documentation In Behavioral Health Care written by Joint Commission on Accreditation of Healthcare Organizations and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 1997-01-01 with Clinical health psychology categories.
Successful Collaboration In Healthcare
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Author : Colleen Stukenberg
language : en
Publisher: CRC Press
Release Date : 2010-01-27
Successful Collaboration In Healthcare written by Colleen Stukenberg and has been published by CRC Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2010-01-27 with Business & Economics categories.
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 toShow how to build trust and communicat
The Clinical Documentation Improvement Specialist S Guide To Icd 10
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Author : Glenn Krauss
language : en
Publisher: HC Pro, Inc.
Release Date : 2011-03
The Clinical Documentation Improvement Specialist S Guide To Icd 10 written by Glenn Krauss and has been published by HC Pro, Inc. this book supported file pdf, txt, epub, kindle and other format this book has been release on 2011-03 with Medical categories.
Take charge of ICD-10 documentation requirements The implementation of ICD-10 brings with it new documentation requirements that will have a significant impact on the work of your CDI team. The higher degree of specificity of information needed to code accurately will have a direct correlation to reimbursement and compliance. CDI specialists need a firm understanding of the new code set, and the rules that govern it, to obtain the appropriate level of documentation from physicians. The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only book that addresses ICD-10 from the CDI point of view. Written by CDI experts, it explains the new 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 conditions such as heart failure, sepsis, and COPD. Learn from your peers The Clinical Documentation Improvement Specialist's Guide to ICD-10 includes case studies from two hospitals that have already begun ICD-10 training so you can use their timelines as a blue print to begin your organization's training and implementation. ICD-10 implementation happens in 2013. It's not too soon to start developing the expertise and comfort level you'll need to manage this important industry change and help your organization make a smooth transition. Benefits: * Tailored exclusively for CDI specialists * Side-by-side comparison of what documentation is necessary now v. what will be required starting October 1, 2013 * Timelines to train physicians in new documentation requirements to ensure readiness by implementation date * Strategies and best practices to ensure physician buy-in
The Clinical Documentation Sourcebook
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Author : Donald E. Wiger
language : en
Publisher: John Wiley & Sons
Release Date : 2010-02-02
The Clinical Documentation Sourcebook written by Donald E. Wiger and has been published by John Wiley & Sons this book supported file pdf, txt, epub, kindle and other format this book has been release on 2010-02-02 with Psychology categories.
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.
Social Work Documentation
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Author : Nancy Sidell
language : en
Publisher:
Release Date : 2023
Social Work Documentation written by Nancy Sidell and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2023 with Communication in social work categories.
"Designed to help practitioners build writing skills in a variety of settings, Social Work Documentation is a how-to guide for social work students and practitioners interested in good record keeping and improving their documentation skills. This popular, must-have resource provides practical advice on current practice issues such as electronic case recording, trauma-informed documentation, and assessing and documenting client cultural differences of relevance. This third edition is updated to view documentation through person-first language, and includes a chapter on bias-free language selection, with examples and exercises to ensure appropriate wording choices are used related to age, disability, immigration and socioeconomic status, and gender and sexual orientation"--
The Book Of Style For Medical Transcription
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Author : Lea M. Sims
language : en
Publisher:
Release Date : 2008-06
The Book Of Style For Medical Transcription written by Lea M. Sims and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2008-06 with Medical records categories.
The Counselor S Steps For Progress Notes
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Author : Rhonda Sutton
language : en
Publisher: Createspace Independent Publishing Platform
Release Date : 2015-06-21
The Counselor S Steps For Progress Notes written by Rhonda Sutton and has been published by Createspace Independent Publishing Platform this book supported file pdf, txt, epub, kindle and other format this book has been release on 2015-06-21 with Counseling categories.
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.
Nursing Documentation In Aged Care
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Author : Christine Crofton
language : en
Publisher:
Release Date : 2004
Nursing Documentation In Aged Care written by Christine Crofton and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2004 with Medical categories.
As another volume in Ausmed's 'Guide to Practice' series of textbooks and audiobooks, this is an essential text for all aged-care nurses who wish to enhance their documentation skills and deliver higher quality care to the elderly. AudioBooks are ideal teaching tools.