Guide to Clinical Documentation

Understand the when, why, and how of clinical record-keeping with this essential guide. Guide to Clinical Documentation provides a straightforward, step-by-step approach to developing the skills needed to master the increasingly complex challenges of documenting patient care. Whether working in an office or hospital setting, this resource teaches practitioners and students how to write effective SOAP notes, document patient care accurately, and write prescriptions with confidence.

The third edition features a wealth of practical examples, exercises, and clear instructions designed to make clinical concepts easy to understand. It goes beyond basic charting to discuss critical factors such as compliance standards, billing codes, and the requirements for reimbursable providers. Recognized as a comprehensive resource for nursing, NP, and PA programs, this book serves as an indispensable reference for mastering professional documentation standards.

Book Details

• Author: Debra D. Sullivan PhD RN PA-C
• Edition: Third Edition
• Publisher: F.A. Davis Company
• Publication Date: August 16, 2018
• ISBN-10: 0803666624
• ISBN-13: 978-0803666627