Detail Cantuman Kembali
Documentation for Health Records
This book provides a comprehensive guide to best practices in documenting health records, with a focus on the importance of accuracy and adherence to industry standards. It is designed for healthcare professionals who are responsible for recording medical information, including physicians, nurses, and medical records technicians. Fahrenholz emphasizes that proper documentation is key to supporting effective clinical decisions, maintaining continuity of patient care, and minimizing legal risk.
The book covers a range of topics, including documentation techniques, industry standards and guidelines, and managing health records in both paper and electronic formats. The authors also discuss the challenges faced in the transition to electronic health record (EHR) systems and provide strategies for ensuring consistent, high-quality documentation in a digital environment. Through case studies, examples of correct and incorrect documentation, and practical exercises, the book provides healthcare professionals with the tools they need to improve their skills in documenting health records.
With its practical, evidence-based approach, this book is an essential resource for anyone involved in managing health information, whether in a clinical or administrative context.
Cheryl Gregg Fahrenholz - Personal Name
651.504261 Fah d
978-1-58426-554-2
651.504261
Text
Inggris
AHIMA Press
2017
Chicago
xxiii, 488 hlm.: ilus.; 30 cm.
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