Documentation for Medical Records
| Author | : Barbara Odom-Wesley |
| Publisher | : |
| Total Pages | : 538 |
| Release | : 2008-08 |
| Genre | : Medical informatics |
| ISBN | : 9781584261834 |
Documentation For Medical Records
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Documentation for Health Records
| Author | : Cheryl Gregg Fahrenholz |
| Publisher | : |
| Total Pages | : 744 |
| Release | : 2013-01-01 |
| Genre | : Medical |
| ISBN | : 9781584262626 |
Registries for Evaluating Patient Outcomes
| Author | : Agency for Healthcare Research and Quality/AHRQ |
| Publisher | : Government Printing Office |
| Total Pages | : 385 |
| Release | : 2014-04-01 |
| Genre | : Medical |
| ISBN | : 1587634333 |
This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.
The Computer-Based Patient Record
| Author | : Committee on Improving the Patient Record |
| Publisher | : National Academies Press |
| Total Pages | : 257 |
| Release | : 1997-10-28 |
| Genre | : Medical |
| ISBN | : 030957885X |
Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.
Guide to Clinical Documentation
| Author | : Debra Sullivan |
| Publisher | : F.A. Davis |
| Total Pages | : 301 |
| Release | : 2011-12-22 |
| Genre | : Medical |
| ISBN | : 0803629974 |
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.
Care of the Acutely Ill Adult
| Author | : Fiona Creed |
| Publisher | : Oxford University Press, USA |
| Total Pages | : 449 |
| Release | : 2020-10-08 |
| Genre | : Medical |
| ISBN | : 0198793456 |
Care of the Acutely Ill Adult equips all nurses with the knowledge and skills to care for deteriorating patients in the clinical environment. With its unique system-based approach, this key book emphasizes systematic assessment, careful monitoring, and timely escalation, and is essential reading for all nurses working in acute care settings.
Medical Record Chart Analyzer
| Author | : Deborah J. Grider |
| Publisher | : American Medical Association Press |
| Total Pages | : 388 |
| Release | : 2002 |
| Genre | : Business & Economics |
| ISBN | : |
The quality of coding is an important factor in determining the financial health of a practice. When problems occur they must be solved quickly. But before they can be solved, they must be found. Medical Record Chart Analyzer includes medical record documentation with a systematic guide to the medical record review process for the physician's or outpatient office. Learning objectives are included at the beginning of most chapters to overview chapter content and help measure progress. Medical chart review and coding tips are located throughout the book. The application exercises allow the reader to master each topic one chapter at a time. Also included is a final examination to test documentation and auditing skills. By the end of the book, the reader will be able to conduct reviews independently. Authored by Deborah J. Grider, CPC, CPC-H, CCS-P, CCP, an experienced professional in the fields of reimbursement, procedural and diagnostic coding, medical practice management and compliance. Readers can earn up to 10 CEU credits from AAPC.
How to Practice Academic Medicine and Publish from Developing Countries?
| Author | : Samiran Nundy |
| Publisher | : Springer Nature |
| Total Pages | : 475 |
| Release | : 2021-10-23 |
| Genre | : Medical |
| ISBN | : 9811652481 |
This is an open access book. The book provides an overview of the state of research in developing countries – Africa, Latin America, and Asia (especially India) and why research and publications are important in these regions. It addresses budding but struggling academics in low and middle-income countries. It is written mainly by senior colleagues who have experienced and recognized the challenges with design, documentation, and publication of health research in the developing world. The book includes short chapters providing insight into planning research at the undergraduate or postgraduate level, issues related to research ethics, and conduct of clinical trials. It also serves as a guide towards establishing a research question and research methodology. It covers important concepts such as writing a paper, the submission process, dealing with rejection and revisions, and covers additional topics such as planning lectures and presentations. The book will be useful for graduates, postgraduates, teachers as well as physicians and practitioners all over the developing world who are interested in academic medicine and wish to do medical research.
Principles and Practice of Hospital Medicine
| Author | : Sylvia McKean |
| Publisher | : McGraw Hill Professional |
| Total Pages | : 2351 |
| Release | : 2011-12-30 |
| Genre | : Medical |
| ISBN | : 0071603905 |
The definitive guide to the knowledge and skills necessary to practice Hospital Medicine Presented in full color and enhanced by more than 700 illustrations, this authoritative text provides a background in all the important clinical, organizational, and administrative areas now required for the practice of hospital medicine. The goal of the book is provide trainees, junior and senior clinicians, and other professionals with a comprehensive resource that they can use to improve care processes and performance in the hospitals that serve their communities. Each chapter opens with boxed Key Clinical Questions that are addressed in the text and hundreds of tables encapsulate important information. Case studies demonstrate how to apply the concepts covered in the text directly to the hospitalized patient. Principles and Practice of Hospital Medicine is divided into six parts: Systems of Care: Introduces key issues in Hospital Medicine, patient safety, quality improvement, leadership and practice management, professionalism and medical ethics, medical legal issues and risk management, teaching and development. Medical Consultation and Co-Management: Reviews core tenets of medical consultation, preoperative assessment and management of post-operative medical problems. Clinical Problem-Solving in Hospital Medicine: Introduces principles of evidence-based medicine, quality of evidence, interpretation of diagnostic tests, systemic reviews and meta-analysis, and knowledge translations to clinical practice. Approach to the Patient at the Bedside: Details the diagnosis, testing, and initial management of common complaints that may either precipitate admission or arise during hospitalization. Hospitalist Skills: Covers the interpretation of common “low tech” tests that are routinely accessible on admission, how to optimize the use of radiology services, and the standardization of the execution of procedures routinely performed by some hospitalists. Clinical Conditions: Reflects the expanding scope of Hospital Medicine by including sections of Emergency Medicine, Critical Care, Geriatrics, Neurology, Palliative Care, Pregnancy, Psychiatry and Addiction, and Wartime Medicine.
Clinical Handbook of Psychiatry & the Law
| Author | : Paul S. Appelbaum |
| Publisher | : Lippincott Williams & Wilkins |
| Total Pages | : 348 |
| Release | : 2007 |
| Genre | : Medical |
| ISBN | : 9780781778916 |
Thoroughly updated for its Fourth Edition, this award-winning handbook gives mental health professionals authoritative guidance on how the law affects their clinical practice. Each chapter presents case examples of legal issues that arise in practice, clearly explains the governing legal rules, their rationale, and their clinical impact, and offers concrete action guides to navigating clinico-legal dilemmas. This edition addresses crucial recent developments including new federal rules protecting patients' privacy, regulations minimizing use of seclusion and restraint, liability risks associated with newer psychiatric medications, malpractice risks in forensic psychiatry, and new structured assessment tools for violence risk, suicidality, and decisional capacity.
