Description

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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