Authoring Patient Records

Author : Michael P. Pagano
Publisher : Jones & Bartlett Publishers
ISBN 13 : 1449663281
Total Pages : 210 pages
Book Rating : 4.85/5 ( download)

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Download or read book Authoring Patient Records: An Interactive Guide written by Michael P. Pagano and published by Jones & Bartlett Publishers. This book was released on 2010-02-11 with total page 210 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Author : Michael P. Pagano
Publisher : Jones & Bartlett Publishers
ISBN 13 : 1449611052
Total Pages : 210 pages
Book Rating : 4.57/5 ( download)

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Download or read book Authoring Patient Records written by Michael P. Pagano and published by Jones & Bartlett Publishers. This book was released on 2010-02-11 with total page 210 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Author : MIT Critical Data
Publisher : Springer
ISBN 13 : 3319437429
Total Pages : 427 pages
Book Rating : 4.22/5 ( download)

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Download or read book Secondary Analysis of Electronic Health Records written by MIT Critical Data and published by Springer. This book was released on 2016-09-09 with total page 427 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book trains the next generation of scientists representing different disciplines to leverage the data generated during routine patient care. It formulates a more complete lexicon of evidence-based recommendations and support shared, ethical decision making by doctors with their patients. Diagnostic and therapeutic technologies continue to evolve rapidly, and both individual practitioners and clinical teams face increasingly complex ethical decisions. Unfortunately, the current state of medical knowledge does not provide the guidance to make the majority of clinical decisions on the basis of evidence. The present research infrastructure is inefficient and frequently produces unreliable results that cannot be replicated. Even randomized controlled trials (RCTs), the traditional gold standards of the research reliability hierarchy, are not without limitations. They can be costly, labor intensive, and slow, and can return results that are seldom generalizable to every patient population. Furthermore, many pertinent but unresolved clinical and medical systems issues do not seem to have attracted the interest of the research enterprise, which has come to focus instead on cellular and molecular investigations and single-agent (e.g., a drug or device) effects. For clinicians, the end result is a bit of a “data desert” when it comes to making decisions. The new research infrastructure proposed in this book will help the medical profession to make ethically sound and well informed decisions for their patients.

Author : M. Beth Shanholtzer
Publisher : McGraw-Hill Education
ISBN 13 : 9781260082265
Total Pages : 304 pages
Book Rating : 4.61/5 ( download)

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Download or read book Integrated Electronic Health Records written by M. Beth Shanholtzer and published by McGraw-Hill Education. This book was released on 2020-06-11 with total page 304 pages. Available in PDF, EPUB and Kindle. Book excerpt: Developed as a comprehensive learning resource, this hands-on course for Integrated Electronic Health Records is offered through McGraw Hill's Connect. Connect uses the latest technology and learning techniques to better connect professors to their students, and students to the information and customized resources they need to master a subject. Both the worktext and the online course include coverage of EHRclinic, an education-based EHR solution for online electronic health records, practice management applications, and interoperable physician-based functionality. EHRclinic will be used to demonstrate the key applications of electronic health records. Attention is paid to providing the "why"behind each task, so that the reader can accumulate transferable skills. The coverage is focused on using an EHR program in a doctor's office, while providing additional information on how tasks might also be completed in a hospital setting.

Author : Committee on Improving the Patient Record
Publisher : National Academies Press
ISBN 13 : 030957885X
Total Pages : 257 pages
Book Rating : 4.51/5 ( download)

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Download or read book The Computer-Based Patient Record written by Committee on Improving the Patient Record and published by National Academies Press. This book was released on 1997-10-28 with total page 257 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Author : Ginge Kettenbach
Publisher : F.A. Davis
ISBN 13 : 080365846X
Total Pages : 295 pages
Book Rating : 4.62/5 ( download)

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Download or read book Writing Patient/Client Notes written by Ginge Kettenbach and published by F.A. Davis. This book was released on 2016-05-11 with total page 295 pages. Available in PDF, EPUB and Kindle. Book excerpt: Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model.

Author : Jeffrey L. Greenwald
Publisher : Elsevier Health Sciences
ISBN 13 : 9781560536024
Total Pages : 84 pages
Book Rating : 4.20/5 ( download)

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Download or read book Writing a History and Physical written by Jeffrey L. Greenwald and published by Elsevier Health Sciences. This book was released on 2003-05-05 with total page 84 pages. Available in PDF, EPUB and Kindle. Book excerpt: Central to providing excellent patient care is excellent communication, for which a well-written History and Physical is crucial. This book is a step-by-step guide to help medical students, nurse practitioners, physician assistants, etc. write a comprehensive, clear, and useful History and Physical. Writing an effective History and Physical is as much an art as science, and this handy guide provides a roadmap for organizing facts in a logical and well-constructed fashion. The text also presents an abridged version for quick reference and a valuable section on how to write daily progress notes. The author's tips pearls, and advice help the reader navigate the principles and goals of the History and Physical Contains more explanations, tips and advice than existing books for what to include and why Memorable good and bad examples reinforce themes in the text

Author : Jean S. Clark
Publisher : HC Pro, Inc.
ISBN 13 : 1601465726
Total Pages : 193 pages
Book Rating : 4.26/5 ( download)

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Download or read book Information Management and Record of Care, Treatment, and Services written by Jean S. Clark and published by HC Pro, Inc.. This book was released on 2009-02 with total page 193 pages. Available in PDF, EPUB and Kindle. Book excerpt: The new, fully updated Information Management and Record of Care, Seventh Edition, is a comprehensive guide to the most current Joint Commission standards, elements of performance for information management and record of care, and the survey process.

Author : Christopher J. Wong
Publisher : Springer
ISBN 13 : 9783031436321
Total Pages : 0 pages
Book Rating : 4.26/5 ( download)

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Download or read book The Patient-Centered Approach to Medical Note-Writing written by Christopher J. Wong and published by Springer. This book was released on 2024-03-10 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Patients are increasingly accessing their own electronic health record, ushering medical chart notes out of the cloistered purview of clinicians and into the age of transparency. With the recognition that patients are reading what is written about them, there is a need for a comprehensive reference on best practices for writing medical notes in this new era. The Patient-Centered Approach to Medical Note-Writing covers important topics including stigmatizing language, the electronic health record, the different parts of a typical medical note, mental health, substance use, difficult encounters, and how to address electronic communication such as test results and patient messages. This book serves as a vital reference for students, residents, fellows and practicing clinicians.

Author : Institute of Medicine
Publisher : National Academies Press
ISBN 13 : 0309185432
Total Pages : 36 pages
Book Rating : 4.31/5 ( download)

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Download or read book Key Capabilities of an Electronic Health Record System written by Institute of Medicine and published by National Academies Press. This book was released on 2003-07-31 with total page 36 pages. Available in PDF, EPUB and Kindle. Book excerpt: Commissioned by the Department of Health and Human Services, Key Capabilities of an Electronic Health Record System provides guidance on the most significant care delivery-related capabilities of electronic health record (EHR) systems. There is a great deal of interest in both the public and private sectors in encouraging all health care providers to migrate from paper-based health records to a system that stores health information electronically and employs computer-aided decision support systems. In part, this interest is due to a growing recognition that a stronger information technology infrastructure is integral to addressing national concerns such as the need to improve the safety and the quality of health care, rising health care costs, and matters of homeland security related to the health sector. Key Capabilities of an Electronic Health Record System provides a set of basic functionalities that an EHR system must employ to promote patient safety, including detailed patient data (e.g., diagnoses, allergies, laboratory results), as well as decision-support capabilities (e.g., the ability to alert providers to potential drug-drug interactions). The book examines care delivery functions, such as database management and the use of health care data standards to better advance the safety, quality, and efficiency of health care in the United States.