I
Copyright q© q2019 qby qF. qA. qDavis qCompany. qAll
qrights qreserved.
,Copyright q© q2019 qby qF. qA. qDavis qCompany. qAll
qrights qreserved.
,Introduction
It’s qno qsecret qthat qmedicine qis qconstantly q doesn’t qmean q“good” qand q“bad”—just qdifferent. qI’m
qchanging qand q evolving, qbut qI qguess qI qdidn’t qof q the qopinion qthat qthe qmore qexamples qyou qsee,
qrealize qthat qthere qhave qbeen q so qmany qthe qmore q you qwill qlearn qand qthe qmore qprepared
qchanges qand qevolutions qin qdocumentation quntil qyou qwill qbe qwhen q it qcomes qtime qfor qyou qto
q I qstarted qworking qon qthe qthird qedition. qdocument qyour qway.
qSince qthe qsecond q edition qwas qpublished qin Revisions qstarted qwith qthe qTable qof qContents, qwhich
q2011, qthere qhave qbeen qsignif- q icant q has q been q expanded q to q highlight q sections
qchanges qin qcoding, qbilling, qreimbursable q within q the
qservices, q federal qrequirements qfor
qdocumentation, qplatforms qfor q documentation,
qand qso qon. qAnd, qthanks qto qthe qfeedback
q from qusers qof qthis qtext qand qthoughtful
qreviews qby qedu- q cators qand qpractitioners,
qthe q“wish qlist” qof qcontent qfor q this qtext
qhas qchanged qas qwell. qSo, qhere qyou qhave
qit, qthe q third—and q by q far, qthe q best—
edition. qOne q thing q that q has qnot qchanged
qis qthe qbasic qprinciple qof qthe qbook—this q is
qan qinstructional qwork qon qdocumentation
qand qis qnot q meant qto qbe qan
qinstructional qwork qon qthe qpractice qof
q medicine. qDocumentation qand qthe qpractice qof
qmedicine q are qinterrelated, qand qit qis
qsometimes qa qchallenge qto qkeep q them
qseparate. qHowever, qthey qare qtwo qdistinctly
qdiffer- q ent qpractices. qAs qan qeducator, qI
qteach. qAs qa qPhysician q Assistant, qI
qpractice qmedicine. qAs qan qauthor, qsometimes
q I qwant qto qdo q both, qbut qthat qhas
qnever qbeen qthe qgoal. q The qgoal qis qto
qprovide qa qsolid qfoundation qof qprinciples
q of qdocumentation qthat qwill qpreserve
qimportant qaspects q of q the q health-care
q provider–patient q encounter q while q meeting
qthe qrequirements qfor qreimbursement qand qother
q regulations. qThere qare qmany qexamples qof
qdocumenta- q tion qof qvarious qencounters
qthroughout qthis qbook, qand q each qis qjust
qone qexample qof qhow qan qencounter qmay
qbe q documented. qThere qis qnot qjust qone
qway qto qdocument q any qencounter qbut
qmany qdifferent qways; qand qdifferent
, chapters qand qto qprovide qmuch —Debbie q Sullivan
qmore qdetail qabout qthe q content. Phoenix, qArizona
qNew qcontent qincludes qChapter q4,
qDocumenting q Prenatal q Care q and
q Perinatal q Events, qand q Chapter
q 7, q Older qAdult qPreventive qCare
qVisits. qSome qchapters qwere q relocated
qwithin qthe qtext qto qpresent qa qmore
qchronological q sequence. qEvery
qchapter qwas qrevised; qsome qrevisions
qwere q fairly qminor, qwhereas qothers
qwere qextensive. qMedicolegal q Alerts
qare qincluded qin qeach qchapter
qto qhelp qhighlight q important
qconcepts. qNew qto qthis qedition qare
qimages qof q electronic qmedical
qrecord q(EMR) qentries, qor qscreen
qshots. q There qare qmultiple qEMR
qsystems qavailable, qso qwhat qis
q presented qmay qlook qdifferent
qfrom qwhat qyou’ve qseen q before,
qbut qI qthink qit qis qhelpful qto
qsee qsample qentries q from
qdifferent qsystems.
Sometimes qAppendices qdon’t qget
qa qlot qof qattention, q but qI qhope
qyou’ll qcheck qout qAppendix qA, qthe
qDocument q Library. qIn qthe qlibrary,
qyou’ll qfind qdocuments qthat qper-
q tain qto qa qparticular qpatient
qgrouped qtogether qin qa qway
q that qcaptures qthe qpatient’s qcare
qchronologically. qThis q provides qa
qdifferent qperspective qthan qseeing
qthem qas q “stand-alone” qdocuments
qin qmultiple qchapters.
Many qeducators qmentioned qthat
qthey qwould qlike qthe q worksheet
qanswers qmoved qout qof qthe qbook
qso qthat qthey q could qbe qused
qmore qeffectively qas qan qeducational
qtool, qso qthis qwas qdone. qYou qcan
qfind qthem qin qthe qInstructor’s
q Guide, qat qDavisPlus qon qthe qF.A.
qDavis qwebsite, qwhich q will qallow
qyou qto qprovide qthem qto qthe
qstudents qas qyou qsee qfit—you qcan
qsimply qprovide qthe qanswers qso
qstudents q can qcheck qtheir qown
qwork, qor qyou qcan quse qthe qworksheets
q as qgraded qassignments.
Whether qyou qare qa qstudent, qa
qnovice qpractitioner, qor qan
q experienced qprovider, qI qhope qthis
qbook qwill qbe qa qvaluable q resource
qin qyour qjourney qof qprofessional
qdevelopment.
Copyright q© q2019 qby qF. qA. qDavis qCompany. qAll xxi
qrights qreserved.
Copyright q© q2019 qby qF. qA. qDavis qCompany. qAll
qrights qreserved.
,Copyright q© q2019 qby qF. qA. qDavis qCompany. qAll
qrights qreserved.
,Introduction
It’s qno qsecret qthat qmedicine qis qconstantly q doesn’t qmean q“good” qand q“bad”—just qdifferent. qI’m
qchanging qand q evolving, qbut qI qguess qI qdidn’t qof q the qopinion qthat qthe qmore qexamples qyou qsee,
qrealize qthat qthere qhave qbeen q so qmany qthe qmore q you qwill qlearn qand qthe qmore qprepared
qchanges qand qevolutions qin qdocumentation quntil qyou qwill qbe qwhen q it qcomes qtime qfor qyou qto
q I qstarted qworking qon qthe qthird qedition. qdocument qyour qway.
qSince qthe qsecond q edition qwas qpublished qin Revisions qstarted qwith qthe qTable qof qContents, qwhich
q2011, qthere qhave qbeen qsignif- q icant q has q been q expanded q to q highlight q sections
qchanges qin qcoding, qbilling, qreimbursable q within q the
qservices, q federal qrequirements qfor
qdocumentation, qplatforms qfor q documentation,
qand qso qon. qAnd, qthanks qto qthe qfeedback
q from qusers qof qthis qtext qand qthoughtful
qreviews qby qedu- q cators qand qpractitioners,
qthe q“wish qlist” qof qcontent qfor q this qtext
qhas qchanged qas qwell. qSo, qhere qyou qhave
qit, qthe q third—and q by q far, qthe q best—
edition. qOne q thing q that q has qnot qchanged
qis qthe qbasic qprinciple qof qthe qbook—this q is
qan qinstructional qwork qon qdocumentation
qand qis qnot q meant qto qbe qan
qinstructional qwork qon qthe qpractice qof
q medicine. qDocumentation qand qthe qpractice qof
qmedicine q are qinterrelated, qand qit qis
qsometimes qa qchallenge qto qkeep q them
qseparate. qHowever, qthey qare qtwo qdistinctly
qdiffer- q ent qpractices. qAs qan qeducator, qI
qteach. qAs qa qPhysician q Assistant, qI
qpractice qmedicine. qAs qan qauthor, qsometimes
q I qwant qto qdo q both, qbut qthat qhas
qnever qbeen qthe qgoal. q The qgoal qis qto
qprovide qa qsolid qfoundation qof qprinciples
q of qdocumentation qthat qwill qpreserve
qimportant qaspects q of q the q health-care
q provider–patient q encounter q while q meeting
qthe qrequirements qfor qreimbursement qand qother
q regulations. qThere qare qmany qexamples qof
qdocumenta- q tion qof qvarious qencounters
qthroughout qthis qbook, qand q each qis qjust
qone qexample qof qhow qan qencounter qmay
qbe q documented. qThere qis qnot qjust qone
qway qto qdocument q any qencounter qbut
qmany qdifferent qways; qand qdifferent
, chapters qand qto qprovide qmuch —Debbie q Sullivan
qmore qdetail qabout qthe q content. Phoenix, qArizona
qNew qcontent qincludes qChapter q4,
qDocumenting q Prenatal q Care q and
q Perinatal q Events, qand q Chapter
q 7, q Older qAdult qPreventive qCare
qVisits. qSome qchapters qwere q relocated
qwithin qthe qtext qto qpresent qa qmore
qchronological q sequence. qEvery
qchapter qwas qrevised; qsome qrevisions
qwere q fairly qminor, qwhereas qothers
qwere qextensive. qMedicolegal q Alerts
qare qincluded qin qeach qchapter
qto qhelp qhighlight q important
qconcepts. qNew qto qthis qedition qare
qimages qof q electronic qmedical
qrecord q(EMR) qentries, qor qscreen
qshots. q There qare qmultiple qEMR
qsystems qavailable, qso qwhat qis
q presented qmay qlook qdifferent
qfrom qwhat qyou’ve qseen q before,
qbut qI qthink qit qis qhelpful qto
qsee qsample qentries q from
qdifferent qsystems.
Sometimes qAppendices qdon’t qget
qa qlot qof qattention, q but qI qhope
qyou’ll qcheck qout qAppendix qA, qthe
qDocument q Library. qIn qthe qlibrary,
qyou’ll qfind qdocuments qthat qper-
q tain qto qa qparticular qpatient
qgrouped qtogether qin qa qway
q that qcaptures qthe qpatient’s qcare
qchronologically. qThis q provides qa
qdifferent qperspective qthan qseeing
qthem qas q “stand-alone” qdocuments
qin qmultiple qchapters.
Many qeducators qmentioned qthat
qthey qwould qlike qthe q worksheet
qanswers qmoved qout qof qthe qbook
qso qthat qthey q could qbe qused
qmore qeffectively qas qan qeducational
qtool, qso qthis qwas qdone. qYou qcan
qfind qthem qin qthe qInstructor’s
q Guide, qat qDavisPlus qon qthe qF.A.
qDavis qwebsite, qwhich q will qallow
qyou qto qprovide qthem qto qthe
qstudents qas qyou qsee qfit—you qcan
qsimply qprovide qthe qanswers qso
qstudents q can qcheck qtheir qown
qwork, qor qyou qcan quse qthe qworksheets
q as qgraded qassignments.
Whether qyou qare qa qstudent, qa
qnovice qpractitioner, qor qan
q experienced qprovider, qI qhope qthis
qbook qwill qbe qa qvaluable q resource
qin qyour qjourney qof qprofessional
qdevelopment.
Copyright q© q2019 qby qF. qA. qDavis qCompany. qAll xxi
qrights qreserved.
