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Writing patient/client notes : ensuring accuracy in documentation
- 자료유형
- 전자책
- n954270975
- ISBN
- 9780803658462 (electronic bk.)
- ISBN
- 080365846X (electronic bk.)
- ISBN
- 9780803638204 (paperback)
- ISBN
- 0803638205 (paperback)
- 미국회청구기호
- RM701.6
- DDC
- 615.8/2-22
- 소장사항
-
MAIN
- 서명/저자
- Writing patient/client notes : ensuring accuracy in documentation / Ginge Kettenbach, Sarah L. Schlomer
- 판사항
- 5th edition.
- 형태사항
- 1 online resource (xiii, 279 pages) : illustrations
- 서지주기
- Includes bibliographical references and index.
- 내용주기
- 완전내용Introduction to documentation -- Part I: The health record. Overview of the health record -- Legal aspects of the health record -- Reimbursement -- Reviewing the health record as a physical therapist -- Part II: Documentation basics. Writing in a health record -- Introduction to note writing -- Medical terminology -- Using abbreviations -- Introduction to documentation using the international classification of functioning, disability, and health (ICF) system -- Part III: Documenting the examination. The patient/client management format: writing history, including the review of systems -- The patient/client management format: writing systems review and tests and measures -- The SOAP note: stating the problem -- The SOAP note: writing subjective (S), including the review of systems -- The SOAP note: writing objective (O) -- Part IV: Documenting the evaluation/assessment (A). Writing the evaluation/assessment (A) -- Writing the diagnosis (A: diagnosis) -- Writing the prognosis (A: prognosis) -- Part V: Documenting the plan of care (P). Writing expected outcomes and anticipated goals -- Documenting the intervention plan -- Part VI: applications of documentation skills. Writing the daily visit note -- The Medicare therapy cap, KX modifiers, and functional limitations reporting (G-codes) -- Applications and variations in note writing -- Appendices. Summary of the patient/client management note contents -- Summary of the SOAP note contents -- Summary of contents of the four types of notes -- Tips for note writing for third-party payors -- Review of systems and systems review forms
- 일반주제명
- Medical History Taking
- 일반주제명
- Writing
- 일반주제명
- MEDICAL Pharmacology.
- 일반주제명
- Medical protocols.
- 일반주제명
- Note-taking.
- 기타저자
- Schlomer, Sarah L.
- 기타형태저록
- Print versionKettenbach, Ginge. Writing patient/client notes : ensuring accuracy in documentation. 5th edition. Philadelphia : F.A. Davis Company, [2016] 9780803638204 0803638205 (DLC) 2015051404 (OCoLC)934020211
- 전자적 위치 및 접속
- 링크정보보기
- Control Number
- yscl:139453
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