Guide to Clinical Documentation

I. Foundations of Documentation

1. Medicolegal Principles of Documentation
2. The Comprehensive History and Physical Examination
3. SOAP Notes

II. Documentation Related to Outpatient Care

4. Prenatal Care Visits and Newborn Physical Examination
5. Pediatric Preventive Care Visits
6. Adult Preventive Care Visits
7. Older Adult Visits
8. Outpatient Charting and Communication
9. Prescription Writing and Electronic Prescribing

III. Documentation Related to Inpatient Care

10. Admitting a Patient to the Hospital
11. Documenting Inpatient Care
12. Discharging Patients from the Hospital

Appendices

A. Document Library
B. A Guide to Sexual History Taking
C. ISMP's List of Error-Prone Abbreviations, Symbols, and Dose Designations

Bibliography

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.