The Clinical Documentation Sourcebook: A Comprehensive Collection of Mental Health Practice Forms, Handouts, and Records
Product Description
With the demands of third-party payers, as well as the need to comply with regulatory agencies in maintaining comprehensive treatment minutes, clinicians are faced with more paperwork than ever. Organized by stage of the treatment administer (Intake; Assessment; Treatment Plotting/Case Notes; Patient Handouts; and Discharge), this sourcebook contains forms a clinician may need in order to make right and complete clinical minutes. It contains both blank forms, as well as completed copies of the forms, illustrating the type of in rank which should be included. Also featured is an acompanying computer disk containing all of the blank forms in ready-to-use word processing files.
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Categories: Specialties Tags: Clinical, Collection, Comprehensive, Documentation, Forms, Handouts, Health, Mental, Practice, Records, Sourcebook
Medical Record Auditor: Documentation Rules and Rationales With Exercises
Medical Record Auditor: Documentation Rules and Rationales With Exercises Books
Product Description
The new edition of “Medical Record Auditor” expands on the first edition’s foundation on the principles of medical record documentation and instructions on how to conduct a medical record audit in the physician’s or outpatient office. This resource teaches the reader to review documentation basics and format chart notes, and gives guidelines and elements required for each level of service. Tools are provided to aid in properly auditing medical minutes, as well as instruction on analyzing and reporting consequences of an audit. Application exercises and a final examination are included to test the reader’s comprehension of the material.This title includes new features such as: a CD-ROM containing all of the answers to the exercises, audit tools and report templates, auditing cases divided by specialty and PowerPoint presentations with summaries from each chapter; extensive coverage of E/M documentation and chart audits; guidelines for auditing radiology and operating room minutes; and, in rank on how to make sure medical minutes which are compliant with current set of laws.
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Categories: Administration & Policy Tags: Auditor, Documentation, Exercises, Medical, Rationales, Record, Rules
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