Description
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Clear, concise, and simple to followâeverything you need to master the documentation process quickly and easilyCommunicating Clinical Decision Making Through Documentation is the top choice for professionals and students seeking complete coverage of the documentation process including billing and coding. It shows how to ensure every service rendered and billed is supported by showing what to document, how to do it, and why it is so important.
This text includes a refreshing student-friendly approach to the topic. You will find an abundance of cases portraying real-life case scenarios and it delivers must-know information on writing patient/client care notes, incorporating document guidelines, documenting clinical decision making (includes evidenc
Table of ContentsContents
Contributors
Preface
Acknowledgements
SECTION 1 How to Write Patient Care Notes1. Introduction, Background, Purpose, and General Rules for Health Information Management
2. Record Organization and General Principles
3. Application of Models for Organization and Guidelines for Content
4. The Electronic Medical Record
5. Content Standardization and Component Requirements
6. Documentation for Pediatrics
7. Documentation for Home Health
8. Documentation for Certified Nursing Homes
SECTION 2 How to Document Clinical Decision-Making9. Evidence-Based Practice
10. Clinical Decision-Making
11. Legal Issues in the Medical Record
12. Utilization Review and Utilization Management
SECTION 3 Payment and Coding13. Coding
14. Documentation Content Principles
15. Alternative Payment Models
SECTION 4 Steps and Framework for Coding and Documentation16. Documentation Writing Examples and Worksheets
Appendix A Abbreviations
Appendix B OASIS D
Appendix C CMS Form 1500 with Instructions
Appendix D ICD-10 Guidelines
Appendix E APTA Guidelines for Physical Therapy Documentation
Appendix F APTA Documentation Review Checklist
Index
