Documentation for medical records
By: Barbara Odom-Wesley and Diann Brown, editors ; Chris L. Meyers, technical editor
Contributors: American Health Information Management Association
Publisher: American Health Information Management Association
Published: 2009
Place of publication: Chicago, Ill
Language: eng
Number of pages: 538
ISBN-13: 9781584261834
Subjects: Medical records; Medical record management; Medical Records; Documentation; Forms and Records Control
Notes: Includes bibliographical references and index.
Table of contents: title: Preface; title: Part I: Clinical documentation and the healthcare delivery system; title: Healthcare delivery / Diann Brown; title: Clinical documentation and the health record / Diann Brown; title: Part II: Utilization of the healthcare record; title: Principal and ancillary functions of the healthcare record / Diann Brown; title: Documentation for statistical reporting and public health / Barbara Odom-Wesley; title: Clinical information and observations / Barbara Odom-Wesley; title: Format of the health record / Barbara Odom-Wesley; title: Best practices in health record documentation / Diann Brown; title: Part III: Organization and management of the health record; title: Accreditation and regulations / Diann Brown; title: Ambulatory care / Susan Rossiter; title: Long-term acute-care and long-term care / Ella L. James; title: Home care and hospice / Margaret J. White; title: Behavioral healthcare / Kathleen M. Munn; title: Glossary; title: Appendices and resources on CD-ROM; title: Appendix A: The complete medical record in a hybrid EHR environment (Parts I, II, and III); title: Appendix B: Surveying the RHIO landscape: a description of current RHIO models, with a focus on patient identification; title: Appendix C: Guidelines for defining the legal health record for disclosure purposes; title: Appendix D: Maintaining a legally sound health record; title: paper and electronic; title: Appendix E: Building an enterprise master person index; title: Appendix F: Standards for the content of the electronic health record; title: Appendix G: Principles of form and screen design; title: Appendix H: Electronic document management as a component of the electronic health record; title: Appendix I: Guidelines for developing a data dictionary.