Guide to Clinical Documentation PDF Third Edition

Guide to Clinical Documentation PDF Third Edition

Right medical documentation is a strict skill that all medical professionals must-have. Medical documentation is in a continuous evolution according to the significant changes in billing, coding, reimbursable services, and insurance requirements. As documentation and medical practice are interrelated and it is hard to keep them separate, however, they are two distinctly different practices. Guide to Clinical Documentation PDF Third Edition is the best-updated edition that provides a solid foundation of principles of documentation that will preserve important aspects of health-care-provider- patient encounters while meeting the requirements for reimbursement and other regulations.


Features of Guide to Clinical Documentation PDF Third Edition.

  • Prepared by Debra D. Sullivan, Lead advanced practice provider, Academic Urology of Arizona.
  • New updated and unique edition of the documentation learning series as the author has worked on a different deep layering of experience and knowledge that makes each edition better.
  • Documentation used to be mostly a memory aid for the provider, a quick note of his or her thoughts about patients’ presentations.
  • The major idea of the book is to teach documentation skills and critical analysis of medical records not to do instructions on medical practice

  • The up-to-date and complete medical record is so important for management and cases treatment inside a hospital or in outpatient clinics.
  • This book will provide you with the ability to analyze examples of documentation, complete worksheets which will help you apply the information as you read it.
  • What distinguishes our book is its ability to recognize when, why, and how. Here’s how to build the abilities you’ll need to conquer the ever-increasingly complicated demands of patient documentation. Step-by-step instructions show you how to write SOAP notes, document patient care in the office and hospital settings, and write prescriptions using a simple ‘how-to’ method. You’ll find a multitude of examples, exercises, and directions to help you comprehend every concept.


Contents of Guide to Clinical Documentation PDF Third Edition.

Part1: Foundations of Documentation

1.1- Medicolegal principles of Documentation

1.2- The comprehensive History and physical examination

1.3- SOAP notes

Part2: Documentation related to outpatient care

2.1- documenting prenatal care and perinatal events

2.2- pediatric preventive care visits

2.3- adult preventive care visits

2.4- older adult preventive care visits

2.5- outpatient charting and communication

2.6- prescription writing and electronic prescribing

Part3: documentation related to inpatient care

3.1- admitting a patient to the hospital

3.2- documenting inpatient care

3.3- discharging patients from hospital

Part4: Appendices

4.1- Document library

4.2- a guide to sexual history taking

4.3- ISMP list of error-prone abbreviations


We show some opinions of book users.

Conely D. said this is fantastic! “When it comes down to it, charting instructions and assistance is a must. Even goes into codes and other aspects of charting that I hadn’t given much thought to before. This book taught me how much more charting, beyond SOAPs, is required to meet compliance criteria. This book, in my opinion, is for anyone learning to chart as a reimbursable provider. D. Conley is a writer who lives in the United States.

Barbie Adam said it was well worth the money. “This is a guide that will accompany you throughout your nursing program…do not rent it; instead, purchase it and use it as a documentation bible.

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