Authoring Patient Records: An Interactive Guide: An Interactive Guide

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Jones & Bartlett Publishers, Oct 25, 2010 - Medical - 194 pages
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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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Contents

An Overview
1
Audience Purpose and Use
7
Developing an Authoring Process
23
Adapting the Reporters Formula
45
Using the Authoring Process
53
Written Dictated and Electronic
65
Electronic Patient Records
76
Email Websites and Social Networking
83
Legal Considerations for Authors
89
Accurate and Complete Records
95
Summary
102
Analyzing Patient Records
117
Authoring Patient Records
139
Final Thoughts on the Authoring Process
179
Index
187
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