Writing patient/client notes : ensuring accuracy in documentation /

Title:

Writing patient/client notes : ensuring accuracy in documentation /

Author:

Kettenbach, Ginge.

Format:

Book

Institution:

MCPHS Worcester

Contents:

Introduction to note writing -- Writing in a medical record -- Medical terminology -- Using abbreviations -- The patient/client management note : writing history -- The patient/client management note : writing the systems review -- The patient/client management note : documenting tests and measures -- The SOAP note : stating the problem -- The SOAP note : writing subjective (S) -- The SOAP note : writing objective (O) -- Writing the evaluation -- Writing the diagnosis -- Writing the prognosis -- Writing expected outcomes (long term goals) -- Writing anticipated goals (short term goals) -- Documenting planned interventions -- Overview of the medical record -- Legal aspects of the medical record -- Reimbursement -- Applications and variations in note writing -- Alternatives : documentation forms, Medicare forms, and computerized documentation -- The future : documentation using the ICF system.

Online access:

No online access

Library holdings:

MCPHS Circulation - Worcester Campus
RM701 .K48 2009 – Available

• Available Temporarily at MCPHS Circulation Desk - Worcester Campus
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