Guide to Clinical Documentation

Learning objectives in each chapter to help you recognize important concepts at the beginning of the chapter, and reinforce what is summarized at the end of each chapter Coverage of -problem-oriented medical records, patients with multiple complaints or multiple conditions Hands-on, problem-based exercises Worksheets at the end of each chapter Examples of "good" and "bad" documentation for evaluation Real-life case studies that illustrate the potential consequences of poor or inaccurate documentation. Explanations of use and terminology of ICD-10-CM codes in billing Boxes highlighting medicolegal considerations.