Guide to Clinical Documentation

Guide to Clinical Documentation

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Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.a€œVa€ codes are used to identify encouna€” ters for reasons other than illness or injury, such as immunizations and ... (1) there is a mismatch of CPT code and description, or (2) the ICDa€”9 code does not justify the procedure or level of service.

Title:Guide to Clinical Documentation
Author:Debra Sullivan
Publisher:F.A. Davis - 2011-12-22


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