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Guide To Clinical Documentation
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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.
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 416 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.
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.
Book Synopsis The Clinical Documentation Improvement Specialist's Guide to ICD-10 by : Glenn Krauss
Download or read book The Clinical Documentation Improvement Specialist's Guide to ICD-10 written by Glenn Krauss and published by HC Pro, Inc.. This book was released on 2011-03 with total page 163 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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
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 2013-08-07 with total page 288 pages. Available in PDF, EPUB and Kindle. Book excerpt: Ensure confident clinical decisions and maximum reimbursement in a variety of practice settings such as acute care, outpatient, home care, and nursing homes with the only systematic approach to documentation for rehabilitation professionals! Revised and expanded, this hands-on textbook/workbook provides a unique framework for maintaining evidence of treatment progress and patient outcomes with a clear, logical progression. Extensive examples and exercises in each chapter reinforce concepts and encourage you to apply what you’ve learned to realistic practice scenarios. UNIQUE! Combination textbook/workbook format reinforces your understanding and tests your ability to apply concepts through practice exercises. UNIQUE! Systematic approach to documenting functional outcomes provides a practical framework for success in numerous practice settings. Case studies show you how to format goals through realistic client examples. Practice exercises provide valuable experience applying concepts to common clinical problems. 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
Book Synopsis The Clinical Documentation Improvement Specialist's Complete Training Guide by : Laurie L. Prescott
Download or read book The Clinical Documentation Improvement Specialist's Complete Training Guide written by Laurie L. Prescott and published by . This book was released on 2014-10-23 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Your new CDI specialist starts in a few weeks. They have the right background to do the job, but need orientation, training, and help understanding the core skills every new CDI needs. Don't spend time creating training materials from scratch. ACDIS' acclaimed CDI Boot Camp instructors have created The Clinical Documentation Improvement Specialist's Complete Training Guide to serve as a bridge between your new CDI specialists' first day on the job and their first effective steps reviewing records. The Clinical Documentation Improvement Specialist's Complete Training Guide is the perfect resource for CDI program managers to help new CDI professionals understand their roles and responsibilities. It will get your staff trained faster and working quicker. This training guide provides: An introduction for managers, with suggestions for training staff and guidance for manual use Sample training timelines Test-your-knowledge questions to reinforce key concepts Case study examples to illustrate essential CDI elements Documentation challenges associated with common diagnoses such as sepsis, pneumonia, and COPD Sample policies and procedures
Download or read book DocuNotes written by Cherie Rebar and published by F.A. Davis. This book was released on 2009-04-10 with total page 203 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
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.
Book Synopsis Clinical Documentation Improvement by : Pamela Carroll Hess
Download or read book Clinical Documentation Improvement written by Pamela Carroll Hess and published by . This book was released on 2015 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
Book Synopsis The Counselor's Steps for Progress Notes by : Rhonda Sutton
Download or read book The Counselor's Steps for Progress Notes written by Rhonda Sutton and published by Createspace Independent Publishing Platform. This book was released on 2015-06-21 with total page 156 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
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.
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 312 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.
Book Synopsis The OTA's Guide to Writing SOAP Notes by : Sherry Borcherding
Download or read book The OTA's Guide to Writing SOAP Notes written by Sherry Borcherding and published by SLACK Incorporated. This book was released on 2007 with total page 244 pages. Available in PDF, EPUB and Kindle. Book excerpt: Written specifically for occupational therapy assistants, The OTA's Guide to Writing SOAP Notes, Second Edition is updated to include new features and information. This valuable text contains the step-by-step instruction needed to learn the documentation required for reimbursement in occupational therapy. With the current changes in healthcare, proper documentation of client care is essential to meeting legal and ethical standards for reimbursement of services. Written in an easy-to-read format, this new edition by Sherry Borcherding and Marie J. Morreale will continue to aid occupational therapy assistants in learning to write SOAP notes that will be reimbursable under Medicare Part B and managed care for different areas of clinical practice. New Features in the Second Edition: - Incorporated throughout the text is the Occupational Therapy Practice Framework, along with updated AOTA documents - More examples of pediatrics, hand therapy, and mental health - Updated and additional worksheets - Review of grammar/documentation mistakes - Worksheets for deciphering physician orders, as well as expanded worksheets for medical abbreviations - Updated information on billing codes, HIPAA, management of health information, medical records, and electronic documentation - Expanded information on the OT process for the OTA to fully understand documentation and the OTA's role in all stages of treatment, including referral, evaluation, intervention plan, and discharge - Documentation of physical agent modalities With reorganized and shorter chapters, The OTA's Guide to Writing SOAP Notes, Second Edition is the essential text to providing instruction in writing SOAP notes specifically aimed at the OTA practitioner and student. This exceptional edition offers both the necessary instruction and multiple opportunities to practice, as skills are built on each other in a logical manner. Templates are provided for beginning students to use in formatting SOAP notes, and the task of documentation is broken down into small units to make learning easier. A detachable summary sheet is included that can be pulled out and carried to clinical sites as a reminder of the necessary contents for a SOAP note. "Answers" are provided for all worksheets so that the text can be used for independent study if desired. Updated information, expanded discussions, and reorganized learning tools make The OTA's Guide to Writing SOAP Notes, Second Edition a must-have for all occupational therapy assistant students! This text is the essential resource needed to master professional documentation skills in today's healthcare environment.
Book Synopsis Nursing Documentation Handbook by : T. M. Marrelli
Download or read book Nursing Documentation Handbook written by T. M. Marrelli and published by . This book was released on 2000 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book The CCDS Exam Study Guide written by and published by HC Pro, Inc.. This book was released on 2010 with total page 155 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Book Synopsis Clinical Documentation Improvement (CDI) Made Easy, 2nd Edition by : Anthony Nkwuaku
Download or read book Clinical Documentation Improvement (CDI) Made Easy, 2nd Edition written by Anthony Nkwuaku and published by Createspace Independent Publishing Platform. This book was released on 2018-02-24 with total page 264 pages. Available in PDF, EPUB and Kindle. Book excerpt: The book provides clear guides on how to perform the vital duties required in obtaining accurate, quality, complete, and specific documentation from the providers so as to reflect the quality of care, severity of illness and risk of mortality of admitted patients during their encounter to the hospital or inpatient rehab. The book is a "must have" for every CDIS or anyone involved in clinical documentation. The book has current ICD-10-CM/PCS update with pertinent information on the 2018 Official Coding Guidelines for Coding and Reporting, Coding Clinic advice, Pay for Performance, sample queries, various disease processes by MDCs, CDI strategy for success in inpatient rehab, rehab impairment group codes and categories, list of all the surgical and MS-DRGs, and much more. Remember, if it was not documented and documented accurately, it never happened.
Book Synopsis Documentation Basics by : Mia Erickson
Download or read book Documentation Basics written by Mia Erickson and published by SLACK Incorporated. This book was released on 2012 with total page 176 pages. Available in PDF, EPUB and Kindle. Book excerpt: Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The new Second Edition of Documentation Basics: A Guide for the Physical Therapist Assistant continues the path of teaching the student and clinician documentation from A to Z.
