GUIDE TO Clinical Documentation

GUIDE TO Clinical Documentation Part Chapter 1: 1 Foundations of Documentation Medicolegal Principles of Documentation 1 Chapter 2 The Comprehensive History and Physical Examination 23 Chapter 3 SOAP Notes 45 Part II: Documentation Related to Outpatient Care Chapter 4 Documenting Prenatal Care and Perinatal Events 79 Chapter 5 Pediatric Preventive Care Visits 93 Chapter 6 Adult Preventive Care Visits 125 Chapter 7 Older Adult Preventive Care Visits 153 Chapter 8 Outpatient Charting and Communication 173 Chapter 9 Prescription Writing and Electronic Prescribing 195 Part III: Chapter 10 Documentation Related to Inpatient Care Admitting a Patient to the Hospital 217 Chapter 11 Documenting Inpatient Care 257 Chapter 12 Discharging Patients from the Hospital 285 Appendices Appendix A Document Library 309 Appendix B A Guide to Sexual History Taking 373 Appendix C ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations 375 Bibliography 377 Index 387