Guide to Clinical Documentation 3rd Edition by Debra D. Sullivan, ISBN-13: 978-0803666627


Guide to Clinical Documentation 3rd Edition by Debra D. Sullivan, ISBN-13: 978-0803666627

[PDF eBook eTextbook]

  • Publisher: ‎ F.A. Davis Company; Third edition (August 16, 2018)
  • Language: ‎ English
  • 416 pages
  • ISBN-10: ‎ 0803666624
  • ISBN-13: ‎ 978-0803666627

Understand the when, why, and how! Here’s your guide to developing the skills you need to master the increasing complex challenges of documenting patient care. Step by step, a straightforward ‘how-to’ approach teaches you how to write SOAP notes, document patient care in office and hospital settings, and write prescriptions. You’ll find a wealth of examples, exercises, and instructions that make every point clear and easy to understand.

Table of Contents:

I. Foundations of Documentation

1. Medicolegal Principles of Documentation

2. The Comprehensive History and Physical Examination

3. SOAP Notes

II. Documentation Related to Outpatient Care

4. Documenting Prenatal Care and Visits and Newborn Physical Examination Perinatal Events

5. Pediatric Preventive Care Visits

6. Adult Preventive Care Visits

7. Older Adult Preventative Care Visits

8. Outpatient Charting and Communication

9. Prescription Writing and Electronic Prescribing

III. Documentation Related to Inpatient Care

10. Admitting a Patient to the Hospital

11. Documenting Inpatient Care

12. Discharging Patients from the Hospital


A. Document Library

B. A Guide to Sexual History Taking

C. ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations



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