Documentation for Health Records

Documentation for Health Records
2nd Ed.
2017 © AHIMA Press
Cheryl Gregg Fahrenholz, RHIA, CCS-P
ISBN-13: 978-1-58426-554-2
Healthcare Informatics, Allied Health, Patient Safety and Quality Improvement


Documentation for Health Records, Second Edition, explains the importance of accurate and timely health record documentation. This textbook addresses fundamental health record documentation requirements and practices a variety of healthcare settings. This new edition expands topics such as information governance, electronic health records and health IT, clinical documentation improvement, and more.

Key Features

  • • New chapters on data analytics and information governance
  • • Outlines basic healthcare documentation principles
  • • Sample record documentation and legal health record guidelines
  • • Provides updates to federal and state requirements and accreditation guidelines
  • • Specialty healthcare settings documentation
  • • Incorporates documentation for acute-care as the practice model
  • • Covers documentation in ambulatory, home health, hospice, and long-term care settings

Table of Contents

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