Cheat Sheets - A Clinical Documentation Workbook

Cheat Sheets - A Clinical Documentation Workbook
Author: MSN MPH Jessica Reeves
Publisher:
Total Pages: 104
Release: 2021-11-19
Genre:
ISBN: 9780578332253

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Attention nursing students, NP students, PA students, med students or new grads - a clinical documentation workbook that is a time- and life-saver!

The Clinical Documentation Sourcebook

The Clinical Documentation Sourcebook
Author: Donald E. Wiger
Publisher: John Wiley & Sons
Total Pages: 338
Release: 2010-02-02
Genre: Psychology
ISBN: 0470527781

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All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.

Guide to Clinical Documentation

Guide to Clinical Documentation
Author: Debra D Sullivan
Publisher: F.A. Davis
Total Pages: 417
Release: 2018-07-25
Genre: Medical
ISBN: 0803669992

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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.

Medical Billing & Coding For Dummies

Medical Billing & Coding For Dummies
Author: Karen Smiley
Publisher: John Wiley & Sons
Total Pages: 355
Release: 2019-12-05
Genre: Medical
ISBN: 1119625440

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The definitive guide to starting a successful career in medical billing and coding With the healthcare sector growing at breakneck speed—it’s currently the largest employment sector in the U.S. and expanding fast—medical billing and coding specialists are more essential than ever. These critical experts, also known as medical records and health information technicians, keep systems working smoothly by ensuring patient billing and insurance data are accurately and efficiently administered. This updated edition provides everything you need to begin—and then excel in—your chosen career. From finding the right study course and the latest certification requirements to industry standard practices and insider tips for dealing with government agencies and insurance companies, Medical Billing & Coding For Dummies has you completely covered. Find out about the flexible employment options available and how to qualify Understand the latest updates to the ICD-10 Get familiar with ethical and legal issues Discover ways to stay competitive and get ahead The prognosis is good—get this book today and set yourself up with the perfect prescription for a bright, secure, and financially healthy future!

Nursing Cheat Sheets

Nursing Cheat Sheets
Author: Jon Haws
Publisher:
Total Pages: 100
Release: 2019-01-04
Genre:
ISBN: 9781793195180

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FULL COLOR Nursing Cheat Sheets It's Time To ACE the NCLEX® Ready to take your studies to the next level? At NRSNG we get it... understanding nursing concepts can be difficult. Wouldn't it be nice to be able to carry around a book that's sol purpose is to break down those tough nursing concepts into concise information? With the Nursing Cheat Sheets, that is exactly what we've done! 76 quick easy to read nursing cheat sheets. Detailed images and graphs that make learning fun and easy! This book contains the most needed, most referenced, and sometimes most confusing information in an easy to read, understand, and remember format. Stop Wasting TimeWith tables, pictures, graphs and more . . . you are ready to soar!Perfect for the new nurse or nursing student looking to save time and energy in their studies.Nursing Cheat Sheets comes in full color!

75 Nurse Cheat Sheets

75 Nurse Cheat Sheets
Author: Aaron Reed
Publisher: Createspace Independent Publishing Platform
Total Pages: 110
Release: 2015-10-18
Genre:
ISBN: 9781517734954

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MASTER THE MOST IMPORTANT INFO! Trim the fat and get the quick facts. Condense your knowledge base so you can skip the fluff, save time, and master your nursing career! The largest collection of nursing labs, medications, assessments, procedures, acronyms, diagrams, mnemonics, equations, conversions, scales, graphs, pictures, & 20 pages of abbreviations and Spanish translations. This enormous mobile phone and eBook reference will replace all of your expensive and bulky laminated clinical sheets. We have poured through the textbooks and publications to serve you the meat and potatoes. Includes detailed tables, diagrams, algorithms, and charting tools. As well as... * Abbreviations * ABG: Analysis * ABG: Interpretation * ACLS: Bradycardia, Stroke, Tachycardia, Acute Coronary Syndrome algorithms * ACLS: Cardiac arrest, Post Cardiac Arrest algorithms * Admit Notes * APGAR * Artificial airway, endotracheal tube, & laryngoscope size by age * Blood Chemistry * Blood Compatibility * Blood Gas Formulas * Blood Products * BLS Algorithm * Body Mass Index & Body Surface Area * Braden Scale * Cardiac Volumes & Pressures * Cardioversion, Defibrillation, & Fluid Challenge by Age * Chest Pain * Coagulation Studies * Code Drugs * Colloids * Complete Blood Count * Conversions: mcg, mg, mL, kg, lbs., mmHg, & cmH2O * Cranial Nerves * Crystalloids * Daily Body Fluids * Deep Tendon Reflex Scale * Discharge Note * Electrolyte Imbalances * Glasgow Coma Scale * Height Conversion Table * High-alert Medications * History & Physical Exam * Ideal Body Weight * Intracranial Pressure Symptoms * Insulin: onset, peak, duration, & appearance * Lead Placement * Levels of Consciousness: characteristics * Lung Volume Descriptions * Lung Volumes: Obstructive vs. Constrictive * Maintenance Hourly Fluids * Major Nerves: motor action, & sensation * Mechanical Ventilation Parameters: abbreviations, formula, normal values * Mini Mental Status Exam * Morse Fall Scale * Murmurs * Muscle Strength * Nerve Root: motor action, sensation, reflex * Orientation & Disorientation Behaviors * Oxygen Tank Factor Equation * Oxygen: device, flow, FIO2, notes * Pacemaker Codes * PFT Special Test Descriptions * PFT Values: calculations per kg, & normal for 70kg * Postpartum & Delivery Note * Preload/Afterload/Contractility * Preoperative, Procedure, & Postoperative Notes * Pressure Ulcers: stage, characteristics, interventions * Respiratory Pattern Diagrams * Serum Drug Levels * Stroke Scale: Cincinnati * Temperature Conversion Table: formula, F to C * Transfusion Reactions * Transfusion Times * Translation: English to Spanish * Transmission-Based Precautions * Urinalysis * Vital Signs, Weight, Height: by age * Weight Conversion Table * Wound Care: products, indications, considerations Prepare, Pass, Perform... with NurseMastery!

Nursing Notes the Easy Way

Nursing Notes the Easy Way
Author: Karen Stuart Gelety
Publisher:
Total Pages: 50
Release: 2010-11-01
Genre: Nursing records
ISBN: 9780975999868

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Ever wonder what to put in a nursing note? This pocket sized guide provides you with over a hundred templates for written and verbal comminication in nursing to help you.

Documentation Manual for Writing SOAP Notes in Occupational Therapy

Documentation Manual for Writing SOAP Notes in Occupational Therapy
Author: Sherry Borcherding
Publisher: Slack Incorporated
Total Pages: 236
Release: 2005
Genre: Medical
ISBN: 9781556427190

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Manual focusing on documenting the occupational therapy process. Each skill is broken down into small steps and taught individually. Includes a template for writing problems, goals, and each section of the SOAP note. Also includes practice worksheets and detachable checklist and summary.

Medical Billing and Coding For Dummies

Medical Billing and Coding For Dummies
Author: Karen Smiley
Publisher: John Wiley & Sons
Total Pages: 388
Release: 2012-06-15
Genre: Medical
ISBN: 1118236149

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The easy way to start a career in medical billing and coding With healthcare providers moving to electronic record systems, data accuracy and efficient data processing is more important than ever. Medical offices need professionally trained billers and coders, either in the office or via telecommute, to handle records for internal and external accessibility and efficiency. Medical Billing & Coding For Dummies gives you everything you need to know to get started in medical billing and coding. It gives you practical, easy-to-follow coverage and advice on how to find a course, educational topics you should review and pursue in order to stay competitive in the field, and the laws and other regulations you'll encounter in your work. Certification requirements and standard industry practices Tips for dealing with government agencies and insurance companies Ethical and legal issues If you're looking to start a career in the popular field of medical billing and coding, this hands-on, friendly guide has you covered!

Clinical Documentation a Clear and Concise Reference

Clinical Documentation a Clear and Concise Reference
Author: Gerardus Blokdyk
Publisher: 5starcooks
Total Pages: 282
Release: 2018-11
Genre:
ISBN: 9780655441892

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Have all basic functions of Clinical Documentation been defined? How do you assess your Clinical Documentation workforce capability and capacity needs, including skills, competencies, and staffing levels? What are the implications of the one critical Clinical Documentation decision 10 minutes, 10 months, and 10 years from now? What is the total cost related to deploying Clinical Documentation, including any consulting or professional services? Risk factors: what are the characteristics of Clinical Documentation that make it risky? Defining, designing, creating, and implementing a process to solve a challenge or meet an objective is the most valuable role... In EVERY group, company, organization and department. Unless you are talking a one-time, single-use project, there should be a process. Whether that process is managed and implemented by humans, AI, or a combination of the two, it needs to be designed by someone with a complex enough perspective to ask the right questions. Someone capable of asking the right questions and step back and say, 'What are we really trying to accomplish here? And is there a different way to look at it?' This Self-Assessment empowers people to do just that - whether their title is entrepreneur, manager, consultant, (Vice-)President, CxO etc... - they are the people who rule the future. They are the person who asks the right questions to make Clinical Documentation investments work better. This Clinical Documentation All-Inclusive Self-Assessment enables You to be that person. All the tools you need to an in-depth Clinical Documentation Self-Assessment. Featuring 668 new and updated case-based questions, organized into seven core areas of process design, this Self-Assessment will help you identify areas in which Clinical Documentation improvements can be made. In using the questions you will be better able to: - diagnose Clinical Documentation projects, initiatives, organizations, businesses and processes using accepted diagnostic standards and practices - implement evidence-based best practice strategies aligned with overall goals - integrate recent advances in Clinical Documentation and process design strategies into practice according to best practice guidelines Using a Self-Assessment tool known as the Clinical Documentation Scorecard, you will develop a clear picture of which Clinical Documentation areas need attention. Your purchase includes access details to the Clinical Documentation self-assessment dashboard download which gives you your dynamically prioritized projects-ready tool and shows your organization exactly what to do next. You will receive the following contents with New and Updated specific criteria: - The latest quick edition of the book in PDF - The latest complete edition of the book in PDF, which criteria correspond to the criteria in... - The Self-Assessment Excel Dashboard, and... - Example pre-filled Self-Assessment Excel Dashboard to get familiar with results generation ...plus an extra, special, resource that helps you with project managing. INCLUDES LIFETIME SELF ASSESSMENT UPDATES Every self assessment comes with Lifetime Updates and Lifetime Free Updated Books. Lifetime Updates is an industry-first feature which allows you to receive verified self assessment updates, ensuring you always have the most accurate information at your fingertips.