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.Her mother had diabetes, diagnosed around the age of 45. ... As you write the SOAP note, consider whether you need to include any pertinent negatives in your documentation. ... A voided urine sample is obtained and results ofa urine dip are as follows: Color: dark amber Clarity: clear Specific gravity: I.O22 pH: 6.5anbsp;...

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


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