NURS 6512N TESTBANK-Guide to Clinical Documentation 3rd Edition by Debra D Sullivan

Part 1: Foundations of Documentation Chapter 1 Medicolegal Principles of Documentation 1 Chapter 2 The Comprehensive History and Physical Examination 23 Chapter 3 SOAP Notes 45 Part II: Documentation Related to Outpa ...

Part 1: Foundations of Documentation Chapter 1 Medicolegal Principles of Documentation 1 Chapter 2 The Comprehensive History and Physical Examination 23 Chapter 3 SOAP Notes 45 Part II: Documentation Related to Outpatient Care Chapter 4 Documenting Prenatal Care and Perinatal Events 79 Chapter 5 Pediatric Preventive Care Visits 93 Chapter 6 Adult Preventive Care Visits 125 Chapter 7 Older Adult Preventive Care Visits 153 Chapter 8 Outpatient Charting and Communication 173 Chapter 9 Prescription Writing and Electronic Prescribing 195 Part III: Documentation Related to Inpatient Care Chapter 10 Admitting a Patient to the Hospital 217 Chapter 11 Documenting Inpatient Care 257 Chapter 12 Discharging Patients from the Hospital 285 Appendices Appendix A Document Library 309 Appendix B A Guide to Sexual History Taking 373 Appendix C ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations 375 Bibliography 377 Index 387 00_Sullivan_FM.indd 9 7/5/18 5:15 PM 00_Sullivan_FM.indd 10 7/5/18 5:15 PM Copyright © 2019 by F. A. Davis Company. All rights reserved. xi Contents Part 1: Foundations of Documentation Chapter 1 Medicolegal Principles of Documentation 1 Learning Outcomes 1 Introduction 1 Medical Considerations of Documentation 2 Legal Considerations of Documentation 2 Other Purposes of Documentation 3 General Principles of Documentation 3 Medical Coding and Billing 5 Evaluation and Management Services 5 International Classi!cation of Diseases Coding 6 Electronic Medical Records 8 Bene!ts of Electronic Medical Records 8 Barriers to Electronic Medical Records 9 Interoperability 9 Meaningful Use 9 Health Insurance Portability and Accountability Act (HIPAA) 10 Health Insurance Portability 10 Electronic Health-Care Transactions 10 The Privacy Rule 10 Security Rule 13 Summary of the Act 14 Summary 14 Worksheets