Learning objectives in each chapter to help you recognize important concepts at the beginning of the chapter, and reinforce what is summarized at the end of each chapter
Coverage of -problem-oriented medical records, patients with multiple complaints or multiple conditions
Hands-on, problem-based exercises
Worksheets at the end of each chapter
Examples of “good” and “bad” documentation for evaluation
Real-life case studies that illustrate the potential consequences of poor or inaccurate documentation.
Explanations of use and terminology of ICD-10-CM codes in billing
Boxes highlighting medicolegal considerations.

Product Features

• Understand the when, why, and how! Here’s your 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. You’ll find a wealth of examples, exercises, and instructions that make every point clear and easy to understand.