Book Name: Guide to Clinical Documentation 3rd Edition
Author: Debra D. Sullivan
Publisher: F.A. Davis Company
ISBN-10, 13: 9780803669994,0803669992
Pages: 336 pages
File size: 11 MB
File format: PDF,EPUB
Guide to Clinical Documentation 3rd Edition Pdf Book Description:
It’s no secret that medicine is constantly changing and evolving, but I guess I didn’t realize that there have been so many changes and evolutions in documentation until I started working on the third edition. Since the second edition was published in 2011, there have been significant changes in coding, billing, reimbursable services, federal requirements for documentation, platforms for documentation, and so on. And, thanks to the feedback from users of this text and thoughtful reviews by educators and practitioners, the “wish list” of content for this text has changed as well. So, here you have it, the third—and by far, the best—edition. One thing that has not changed is the basic principle of the book—this is an instructional work on documentation and is not meant to be an instructional work on the practice of medicine. Documentation and the practice of medicine are interrelated, and it is sometimes a challenge to keep them separate. However, they are two distinctly different practices. As an educator, I teach. As a Physician Assistant, I practice medicine. As an author, sometimes I want to do both, but that has never been the goal. The goal is to provide a solid foundation of principles of documentation that will preserve important aspects of the health-care provider–patient encounter while meeting the requirements for reimbursement and other regulations. There are many examples of documentation of various encounters throughout this book, and each is just one example of how an encounter may be documented. There is not just one way to document any encounter but many different ways; and different doesn’t mean “good” and “bad”—just different. I’m of the opinion that the more examples you see, the more you will learn and the more prepared you will be when it comes time for you to document your way.
You might be asking, “Why a book on documentation?” Documentation is one of the most important skills a health-care provider can learn. You might feel tempted to focus considerably more time and energy on learning other skills, such as physical examination, suturing, or pharmacotherapeutics. These are essential skills, but documentation is likewise extremely important. State licensure laws and regulations, accrediting bodies, professional organizations, and federal reimbursement programs all require that health-care providers maintain a record for each of their patients.
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