Description
Book SynopsisYour 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.
Table of Contents
- I. Foundations of Documentation
- 1. Medicolegal Principles of Documentation
- 2. The Comprehensive History and Physical Examination
- 3. SOAP Notes
- II. Documentation Related to Outpatient Care
- 4. Prenatal Care Visits and Newborn Physical Examination
- 5. Pediatric Preventive Care Visits
- 6. Adult Preventive Care Visits
- 7. Older Adult Visits
- 8. Outpatient Charting and Communication
- 9. Prescription Writing and Electronic Prescribing
- III. Documentation Related to Inpatient Care
- 10. Admitting a Patient to the Hospital
- 11. Documenting Inpatient Care
- 12. Discharging Patients from the Hospital
- Appendices
- A. Document Library
- B. A Guide to Sexual History Taking
- C. ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations
- Bibliography
