Authoring Patient Records: An Interactive Guide: An Interactive Guide
Authoring Patient Records: An Interactive Guide presents both the theory and rationale for the process of developing medical records, as well as opportunities for readers to practice the new skill. Each chapter discusses how to use the authoring process to create effective records, using examples and sample documents to help illustrate potential problems and solutions. This text has an interactive format including margin notes to help the reader assess his/her understanding, as well as opportunities to practice the authoring process being discussed. An instructor’s manual for online use is also included. Authoring Patient Records: An Interactive Guide is relevant to the training and work of: MDs, PAs, NPs, RNs, PTs, and RTs. The text will be a helpful resource in teaching health care students and as a reference for health care practitioners.
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Audience Purpose and Use
Developing an Authoring Process
Adapting the Reporters Formula
Using the Authoring Process
Written Dictated and Electronic
Electronic Patient Records
Email Websites and Social Networking
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abbreviations abdominal Abdominal Exam addition allergies analyze Apgar score assess author’s authoring patient records authoring process authors of patient Barium enema Chapter checklist Chest Chief Complaint clinical communication effectiveness Costello create credibility critical thinking decision diagnosis dictated Discharge Summary discussed e-mail effective communication electronic patient records ensure evaluate exam example expectations and needs findings format gallbladder goals handwritten records healthcare healthcare providers hematemesis hematochezia hospital important injury intended interaction Joint Commission late entry legibility malpractice risks medical malpractice narrative needs and expectations nurse–author’s Nurse’s Note nurses Pagano pain Pathology Report patient document patient’s complaints patient’s condition Phenergan physical examination Physical Therapy Physician Assistant PIP joint potential pre-authoring analysis primary and secondary primary audiences problems professional proofreading provider–author provider’s purposes for authoring questions Reporter’s Formula revised secondary audiences secondary readers Skills Application SOAP Note thumb tion treatment plan understand vital signs x-ray