Guide to Clinical Documentation
by Debra D. Sullivan Phd Rn Pa-C
Guide to Clinical Documentation offers a straightforward, step-by-step approach to mastering essential patient-care documentation. It covers SOAP notes, office and hospital records, and prescription writing, while providing examples, exercises, and clear instructions to support learning and strengthen practical documentation skills.
About This Book
Guide to Clinical Documentation presents a practical introduction to documenting patient care.
The book covers when, why, and how to document, with attention to the increasing complexity of clinical records.
Readers are guided through writing SOAP notes and documenting care in office and hospital settings.
It also addresses prescription writing and uses examples, exercises, and step-by-step instructions to clarify key points.
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