Documentation for Health Records


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Documentation for Health Records explains the importance of accurate and timely health record documentation. This textbook addresses fundamental health record documentation requirements and practices in language understandable to the student new to the study of healthcare administration.

The book begins with the basics of documentation standards based on the acute care setting, and includes separate chapters on ambulatory care, long-term care, home care and hospice, and behavioral care settings. Documentation for Health Records addresses issues related to both paper and electronic health records appropriate to each environment.

Key Features
  • Sample paper forms
  • EHR screen shots
  • Accreditation and certification standards
  • Applicable governmental regulations
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