Writing patient/client notes ensuring accuracy in documentation George Kettenbach
Material type: TextPublication details: Philadelphia, PA F.A. Davis Company 2009Edition: 4th edDescription: xi, 248 pISBN:- 9780803618787
- 616.09
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 |
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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