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Writing patient/client notes ensuring accuracy in documentation George Kettenbach

By: Material type: TextTextPublication details: Philadelphia, PA F.A. Davis Company 2009Edition: 4th edDescription: xi, 248 pISBN:
  • 9780803618787
Subject(s): Genre/Form: DDC classification:
  • 616.09
Contents:
Background Information; Introduction to Note Writing; Writing in a Medical Record; Medical Terminology/Worksheets; Using Abbreviations/Worksheets; II. Documenting the Examination; The Patient/Client Management Format: Writing History/Worksheets; The Patient/Client Management Format: Writing Systems Review/Worksheets; The Patient/Client Management Format: Documenting Tests and Measures/Worksheets Review Worksheet: Writing the History, Systems Review, and Tests and Measures; The SOAP Note: Stating the Problem; The SOAP Note: Writing Subjective (S)/Worksheets; The SOAP Note: Writing Objective (O)/Worksheets Review Worksheet: Stating the Problem, S & O; III. Documenting the Evaluation (A); Writing Evaluation; Writing the Diagnosis the ICF System; Appendix A: Answers to Worksheets; Appendix B: Summary of the Patient/Client Management Note Contents; Appendix C: Summary of the SOAP Note Contents; Appendix D: Tips for Note Writing for Third Party Payers.
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Holdings
Item type Current library Home library Shelving location Call number Copy number Status Date due Barcode Item holds
4 Week Loan St. Luke's General Hospital Kilkenny St. Luke's General Hospital Kilkenny Open Shelves 616.09 (Browse shelf(Opens below)) 1 Available 031024
Total holds: 0

Includes bibliographical references and index

Background Information; Introduction to Note Writing; Writing in a Medical Record; Medical Terminology/Worksheets; Using Abbreviations/Worksheets; II. Documenting the Examination; The Patient/Client Management Format: Writing History/Worksheets; The Patient/Client Management Format: Writing Systems Review/Worksheets; The Patient/Client Management Format: Documenting Tests and Measures/Worksheets Review Worksheet: Writing the History, Systems Review, and Tests and Measures; The SOAP Note: Stating the Problem; The SOAP Note: Writing Subjective (S)/Worksheets; The SOAP Note: Writing Objective (O)/Worksheets Review Worksheet: Stating the Problem, S & O; III. Documenting the Evaluation (A); Writing Evaluation; Writing the Diagnosis the ICF System; Appendix A: Answers to Worksheets; Appendix B: Summary of the Patient/Client Management Note Contents; Appendix C: Summary of the SOAP Note Contents; Appendix D: Tips for Note Writing for Third Party Payers.

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