Authoring Patient Records: An Interactive Guide

Authoring Patient Records: An Interactive Guide presents both the theory and rationale for the process of developing medical records, as well as opportunities for readers to practice the new skill. Each chapter will discuss how to use the authoring process to create effective records, using examples and sample documents to help illustrate potential problems and solutions. The book will also have space for practicing the process and assignments that can be completed in writing or on a computer. These practice assignments allow the reader to actively learn and become interactive in the actual process of developing the medical record. An instructorrs"s manual for online use is also included. Authoring Patient Records: An Interactive Guide is relevant to the training and work of: MDs, PAs, NPs, RNs, PTs, and RTs. The text will be a helpful resource in teaching health care students and as a reference for health care practitioners.

Chapter1 The Patient Record - An Overview
Chapter2 Audience, Purpose, and Use
Chapter3 Developing an Authoring Process
Chapter4 Adapting the Reporter's Formula
Chapter5 Using the Authoring Process
Chapter6 Written, Dictated, & Electronic Patient Records
Chapter7 Legal Considerations for Authors of Patient Records
Chapter8 Practicing the Process
Chapter9 Analyzing Patient Records
Chapter10 Authoring Patient Records
Chapter11 Final Thoughts on the Authoring Process