Clinical Documentation Reference Guide - First Edition

Download Clinical Documentation Reference Guide - First Edition PDF Online Free

Author :
Publisher : AAPC
ISBN 13 : 1626889791
Total Pages : 13 pages
Book Rating : 4.6/5 (268 download)

DOWNLOAD NOW!


Book Synopsis Clinical Documentation Reference Guide - First Edition by : AAPC

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.

Guide to Clinical Documentation

Download Guide to Clinical Documentation PDF Online Free

Author :
Publisher : F.A. Davis
ISBN 13 : 0803629974
Total Pages : 301 pages
Book Rating : 4.8/5 (36 download)

DOWNLOAD NOW!


Book Synopsis Guide to Clinical Documentation by : Debra Sullivan

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.

Clinical Documentation Reference Guide

Download Clinical Documentation Reference Guide PDF Online Free

Author :
Publisher :
ISBN 13 : 9781646319961
Total Pages : 0 pages
Book Rating : 4.3/5 (199 download)

DOWNLOAD NOW!


Book Synopsis Clinical Documentation Reference Guide by :

Download or read book Clinical Documentation Reference Guide written by and published by . This book was released on 2023 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Coding for Medical Necessity Reference Guide - First Edition

Download Coding for Medical Necessity Reference Guide - First Edition PDF Online Free

Author :
Publisher : AAPC
ISBN 13 : 1626889805
Total Pages : 17 pages
Book Rating : 4.6/5 (268 download)

DOWNLOAD NOW!


Book Synopsis Coding for Medical Necessity Reference Guide - First Edition by : AAPC

Download or read book Coding for Medical Necessity Reference Guide - First Edition written by AAPC and published by AAPC. This book was released on 2020-03-18 with total page 17 pages. Available in PDF, EPUB and Kindle. Book excerpt: Master coding concepts related to medical necessity and report compliant codes for your services. Revenue loss, rework, payback demands—how much are medical necessity errors costing your practice? And that’s to say nothing of potential civil penalties. Get medical necessity wrong and it’s considered a “knowingly false” act punishable under the FCA. Stay liability-free and get reimbursed for your services with reliable medical necessity know-how. AAPC’s Coding for Medical Necessity Reference Guide provides you with step-by-step tutorials to remedy the range of documentation and coding issues at the crux of medical necessity claim errors. Learn how to integrate best practices within your clinical processes—including spot-checks and self-audits to identify problems. Benefit from real-world reporting examples, Q&A, and expert guidance across specialties to master coding for medical necessity. Learn how to lock in medical necessity and keep your practice safe and profitable: Avoid Medical Necessity Errors with CERT Smarts Rules to Improve Provider Documentation Denials? Pay Attention to Procedure/Diagnosis Linkage Nail Down the Ins and Outs of Time-based Coding Expert Guidance to Fend Off RAC Audits and Denials Beat E/M Coding Confusion with Payer Advice Improve Your ABN Know How with This FAQ

The Clinical Documentation Sourcebook

Download The Clinical Documentation Sourcebook PDF Online Free

Author :
Publisher : John Wiley & Sons
ISBN 13 : 0470527781
Total Pages : 338 pages
Book Rating : 4.4/5 (75 download)

DOWNLOAD NOW!


Book Synopsis The Clinical Documentation Sourcebook by : Donald E. Wiger

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.

Evaluation and Management Coding Reference Guide - First Edition

Download Evaluation and Management Coding Reference Guide - First Edition PDF Online Free

Author :
Publisher : AAPC
ISBN 13 : 162688983X
Total Pages : 14 pages
Book Rating : 4.6/5 (268 download)

DOWNLOAD NOW!


Book Synopsis Evaluation and Management Coding Reference Guide - First Edition by : AAPC

Download or read book Evaluation and Management Coding Reference Guide - First Edition written by AAPC and published by AAPC. This book was released on 2020-06-30 with total page 14 pages. Available in PDF, EPUB and Kindle. Book excerpt: Defeat the challenges that threaten your E/M claims and compliance success. Evaluation and management (E/M) services are the lifeblood of your revenue stream, and yet they’re the most problematic to report. Claim denials remain high. E/M coding errors, in fact, rose from 11.9% in 2018 to account for 12.8% of CMS’s overall 2019 improper payment rate. How much E/M revenue are you losing? Safeguard your organization from claim denials and audit scrutiny with the Evaluation & Management Coding Reference Guide. Our experts break down E/M coding rules and requirements into simple, manageable steps written in everyday language to boost your E/M reporting skills. Learn how to capture the key components of medical history, physical exam, and medical decision-making—and capitalize on real-world clinical scenarios to prevent over- or under-coding. The Evaluation & Management Coding Reference Guide will help you prep for 2021 E/M guideline changes overhauling new and established office and outpatient services, and walk you through online digital E/M services, remote physiologic monitoring, and more. Master the ins and outs of E/M coding—CPT® guidelines, level of service, modifiers, regulations, and documentation guidelines. Put an end to avoidable denials and optimize your E/M claims for full and prompt reimbursement. Benefit from expert tutorials covering the spectrum of E/M reporting concepts and challenges: Prep for 2021 guideline changes and their impact on your organization Master the ins and outs of E/M guidelines in CPT® Capture the seven components of E/M services Sort out medical decision-making coding Avoid the pitfalls of time-based coding Nail down specifics for critical care E/M services Clear up modifier confusion Understand NPPs rules for same-day E/M services Take the guesswork out of complexity determinations Get the details on coding surgery and E/M together Learn the principles of E/M documentation

The Clinical Documentation Improvement Specialist's Handbook, Second Edition

Download The Clinical Documentation Improvement Specialist's Handbook, Second Edition PDF Online Free

Author :
Publisher : HC Pro, Inc.
ISBN 13 : 1601467753
Total Pages : 171 pages
Book Rating : 4.6/5 (14 download)

DOWNLOAD NOW!


Book Synopsis The Clinical Documentation Improvement Specialist's Handbook, Second Edition by : Heather Taillon

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

Denials Management & Appeals Reference Guide - First Edition

Download Denials Management & Appeals Reference Guide - First Edition PDF Online Free

Author :
Publisher : AAPC
ISBN 13 : 1626889821
Total Pages : 16 pages
Book Rating : 4.6/5 (268 download)

DOWNLOAD NOW!


Book Synopsis Denials Management & Appeals Reference Guide - First Edition by : AAPC

Download or read book Denials Management & Appeals Reference Guide - First Edition written by AAPC and published by AAPC. This book was released on 2020-03-17 with total page 16 pages. Available in PDF, EPUB and Kindle. Book excerpt: Recoup lost time and revenue with denials management and appeals know-how. Claim denials can sink a profit margin. And given the cost of appeals, roughly $118 per claim, not all denials can be reworked. A practice submitting 50 claims a day at an average reimbursement rate of $200 per claim should bring in $10,000 in daily revenue. But if 10% of those claims are denied, and the practice can only appeal one, they lose $800 per day—upwards of $200K annually. Your medical claims are the lifeblood of operations. Don’t compromise your financial health. Learn how to preempt denials with the Denials Management & Appeals Reference Guide. This vital resource will equip you to get ahead of payers by simplifying the leading causes of denials and showing you how to address insufficient documentation, failing to establish medical necessity, coding and billing errors, coverage stipulations, and untimely filing. Rely on AAPC to walk you through the appeal process. We’ll help you establish protocols to avoid an appeals backlog and teach you how to identify and prioritize denials likely to win an appeal. What’s more, you’ll learn when a claim can be “reopened” to fix a problem. Collect the revenue your practice deserves with effective denials and appeals solutions: Know how to analyze your denials Defeat documentation and compliance issues for successful claims success Utilize payer policy for coverage clues Lock in revenue with face-to-face reimbursement guidance Refine efforts to avoid E/M claim denials Ace ICD-10 coding for optimum reimbursement Put an end to modifier confusion Stave off denials with CCI edits advice Navigate the appeals process like a pro And much more!

Successful Collaboration in Healthcare

Download Successful Collaboration in Healthcare PDF Online Free

Author :
Publisher : CRC Press
ISBN 13 : 1439812934
Total Pages : 138 pages
Book Rating : 4.4/5 (398 download)

DOWNLOAD NOW!


Book Synopsis Successful Collaboration in Healthcare by : Colleen Stukenberg

Download or read book Successful Collaboration in Healthcare written by Colleen Stukenberg and published by CRC Press. This book was released on 2010-01-27 with total page 138 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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 Psychotherapy Documentation Primer

Download The Psychotherapy Documentation Primer PDF Online Free

Author :
Publisher : John Wiley & Sons
ISBN 13 : 1119709938
Total Pages : 288 pages
Book Rating : 4.1/5 (197 download)

DOWNLOAD NOW!


Book Synopsis The Psychotherapy Documentation Primer by : Donald E. Wiger

Download or read book The Psychotherapy Documentation Primer written by Donald E. Wiger and published by John Wiley & Sons. This book was released on 2020-11-10 with total page 288 pages. Available in PDF, EPUB and Kindle. Book excerpt: Everything you need to know to record client intake, treatment, and progress—incorporating the latest managed care, accrediting agency, and government regulations Paperwork and record keeping are day-to-day realities in your mental health practice. Records must be kept for managed care reimbursement; for accreditation agencies; for protection in the event of lawsuits; to meet federal HIPAA regulations; and to help streamline patient care in larger group practices, inpatient facilities, and hospitals. The standard professionals and students have turned to for quick and easy, yet comprehensive, guidance to writing a wide range of mental health documents, the Fourth Edition of The Psychotherapy Documentation Primer continues to reflect HIPAA and accreditation agency requirements as well as offer an abundance of examples. Fully updated to include diagnostic criteria of the DSM-5, The Psychotherapy Documentation Primer, 4th Edition is designed to teach documental skills for the course of psychotherapy from the initial interview to the discharge. The documentation principles discussed in the text satisfy the often-rigid requirements of third-party insurance companies, regulating agencies, mental health licensing boards, and federal HIPAA regulations. More importantly, it provides students and professionals with the empirical and succinct documentation techniques and skills that will allow them to provide clear evidence of the effects of mental health treatment while also reducing the amount of their time spent on paperwork.

Guide to Clinical Documentation

Download Guide to Clinical Documentation PDF Online Free

Author :
Publisher : F.A. Davis
ISBN 13 : 0803669992
Total Pages : 417 pages
Book Rating : 4.8/5 (36 download)

DOWNLOAD NOW!


Book Synopsis Guide to Clinical Documentation by : Debra D Sullivan

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 417 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.

Clinical Documentation Improvement

Download Clinical Documentation Improvement PDF Online Free

Author :
Publisher : Createspace Independent Publishing Platform
ISBN 13 : 9781519538185
Total Pages : 246 pages
Book Rating : 4.5/5 (381 download)

DOWNLOAD NOW!


Book Synopsis Clinical Documentation Improvement by : Rn Phn Nkwuaku, Msn Cphq

Download or read book Clinical Documentation Improvement written by Rn Phn Nkwuaku, Msn Cphq and published by Createspace Independent Publishing Platform. This book was released on 2015-12-17 with total page 246 pages. Available in PDF, EPUB and Kindle. Book excerpt: Clinical Documentation Improvement (CDI) Made Easy is a great resource and reference that every Clinical Documentation Improvement Specialist/Professional (CDIS/CDIP), coder, physician champion/advisor, and others involved in the CDI must have. The book is a compendium of sound clinical knowledge and experience, clinical documentation expertise, and quality, which will help the CDIS/CDIP and others maximize their potentials in performing their core duties. Whether you are a new CDIS trying to learn CDI or an experienced CDIS hoping to stay current with CDI world, or involved in the CDI, this book will be very valuable to you. Remember, accurate and quality documentation is a reflection of great patient care. "If it wasn't documented, and documented accurately, it never happened." This book clearly explained various query opportunities by Major Disease Classifications (MDCs) with some sample queries. It defines and analyses different disease processes, creates CDIS awareness and what to look for under various MDCs, ICD-10-CM/PCS, explained current CMS Pay for Performance (P4P), and the CDI responsibility under P4P, explained some pertinent coding guidelines, 2016 Official Coding Guidelines for Coding and Reporting, AHIMA/ACDIS practice brief for queries and compliance, and much more. I have no doubt in my mind that this book is a concise but a comprehensive tool and reference that anyone involved in CDI should always have at his/her side. The Author Anthony O Nkwuaku, RN, PHN, MSN, CPHQ, CCDS is very knowledgeable and experienced as a clinician, clinical instructor, and Clinical Documentation Improvement Specialist.

Suggestions to Medical Authors and A.M.A. Style Book

Download Suggestions to Medical Authors and A.M.A. Style Book PDF Online Free

Author :
Publisher :
ISBN 13 :
Total Pages : 72 pages
Book Rating : 4.F/5 ( download)

DOWNLOAD NOW!


Book Synopsis Suggestions to Medical Authors and A.M.A. Style Book by : American Medical Association

Download or read book Suggestions to Medical Authors and A.M.A. Style Book written by American Medical Association and published by . This book was released on 1919 with total page 72 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Documentation for Rehabilitation- E-Book

Download Documentation for Rehabilitation- E-Book PDF Online Free

Author :
Publisher : Elsevier Health Sciences
ISBN 13 : 0323266363
Total Pages : 280 pages
Book Rating : 4.3/5 (232 download)

DOWNLOAD NOW!


Book Synopsis Documentation for Rehabilitation- E-Book by : Lori Quinn

Download or read book Documentation for Rehabilitation- E-Book written by Lori Quinn and published by Elsevier Health Sciences. This book was released on 2009-12-18 with total page 280 pages. Available in PDF, EPUB and Kindle. Book excerpt: Four NEW chapters address additional aspects of documentation that rehabilitation professionals will encounter in practice: Legal aspects of documentation Documentation in pediatrics Payment policy and coding Computerized documentation

Complete Guide to Documentation

Download Complete Guide to Documentation PDF Online Free

Author :
Publisher : Lippincott Williams & Wilkins
ISBN 13 : 9781582555560
Total Pages : 454 pages
Book Rating : 4.5/5 (555 download)

DOWNLOAD NOW!


Book Synopsis Complete Guide to Documentation by : Lippincott Williams & Wilkins

Download or read book Complete Guide to Documentation written by Lippincott Williams & Wilkins and published by Lippincott Williams & Wilkins. This book was released on 2008 with total page 454 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

The Physician Documentation Improvement Pocket Guide, Third Edition

Download The Physician Documentation Improvement Pocket Guide, Third Edition PDF Online Free

Author :
Publisher :
ISBN 13 : 9781556452185
Total Pages : 0 pages
Book Rating : 4.4/5 (521 download)

DOWNLOAD NOW!


Book Synopsis The Physician Documentation Improvement Pocket Guide, Third Edition by : Cheryl Ericson

Download or read book The Physician Documentation Improvement Pocket Guide, Third Edition written by Cheryl Ericson and published by . This book was released on 2014-10-22 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Physician Documentation Improvement Pocket Card, Third Edition (Packs of 25) Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer Sold in packages of 25! Use the Physician Documentation Improvement Pocket Card, Third Edition, to help your physicians remember key documentation points. The six-panel card includes everything from documentation basics to severity of illness clinical indicators. Updated for 2014, this third edition simplifies tips to common documentation improvement opportunities. And it fits easily in the physician's pocket! Start your CDI physician education efforts with the accompanying online instruction manual and help physicians understand common documentation gaps. This product: Provides documentation basics for the short-term acute care inpatient setting Includes tips for discharge summary documentation Details documentation needed to establish a condition as a reportable diagnosis Presents key reminders for documentation to reflect patient acuity Offers advice for how to differentiate among acute, chronic, and resolved conditions Helps providers translate commonly vague documentation of a patient's chief complaint into a more precisely associated diagnosis Includes both printed pocket card and online PDF formats Folds for physicians to carry in their pockets and is laminated for durability and easy cleaning The latest edition of the Physician Documentation Improvement Pocket Card helps you improve patient acuity and severity by focusing on common areas of vague and nonspecific physician documentation. ACDIS Education Director and lead CDI Boot Camp instructor Cheryl Ericson brings her vast experience to bear in creating a simple to follow, easy to use tip sheet and accompanying user's guide to help improve your physicians' documentation. Online user manual will explain how to use the pocket cards and explain some CDI basics.

Nursing Documentation Made Incredibly Easy

Download Nursing Documentation Made Incredibly Easy PDF Online Free

Author :
Publisher : Lippincott Williams & Wilkins
ISBN 13 : 1496394747
Total Pages : 487 pages
Book Rating : 4.4/5 (963 download)

DOWNLOAD NOW!


Book Synopsis Nursing Documentation Made Incredibly Easy by : Kate Stout

Download or read book Nursing Documentation Made Incredibly Easy written by Kate Stout and published by Lippincott Williams & Wilkins. This book was released on 2018-06-05 with total page 487 pages. Available in PDF, EPUB and Kindle. Book excerpt: Publisher's Note: Products purchased from 3rd Party sellers are not guaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product. Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy!®, 5th Edition. Packed with colorful images and clear-as-day guidance, this friendly reference guides you through meeting documentation requirements, working with electronic medical records systems, complying with legal requirements, following care planning guidelines, and more. Whether you are a nursing student or a new or experienced nurse, this on-the-spot study and clinical guide is your ticket to ensuring your charting is timely, accurate, and watertight. Let the experts walk you through up-to-date best practices for nursing documentation, with: NEW and updated, fully illustrated content in quick-read, bulleted format NEWdiscussion of the necessary documentation process outside of charting—informed consent, advanced directives, medication reconciliation Easy-to-retain guidance on using the electronic medical records / electronic health records (EMR/EHR) documentation systems, and required charting and documentation practices Easy-to-read, easy-to-remember content that provides helpful charting examples demonstrating what to document in different patient situations, while addressing the different styles of charting Outlines the Do's and Don’ts of charting – a common sense approach that addresses a wide range of topics, including: Documentation and the nursing process—assessment, nursing diagnosis, planning care/outcomes, implementation, evaluation Documenting the patient’s health history and physical examination The Joint Commission standards for assessment Patient rights and safety Care plan guidelines Enhancing documentation Avoiding legal problems Documenting procedures Documentation practices in a variety of settings—acute care, home healthcare, and long-term care Documenting special situations—release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behavior Special features include: Just the facts – a quick summary of each chapter’s content Advice from the experts – seasoned input on vital charting skills, such as interviewing the patient, writing outcome standards, creating top-notch care plans “Nurse Joy” and “Jake” – expert insights on the nursing process and problem-solving That’s a wrap! – a review of the topics covered in that chapter About the Clinical Editor Kate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport, North Carolina.