Guide to Clinical Documentation - Paperback

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.

See what practitioners and students are saying online...

Definitely worth the purchase."This is a guide which will stay with you during your whole nursing program...so do not rent you must buy it and think of it as a documentation bible!"--Barbie

Great resource for NP/PA school."Purchased this for my NP program. The book made writing SOAP notes and H&Ps very simple! Would recommend as a great resource"--Dr. Jon

Love this! "Right down to it charting instructions and guidance. Even discusses codes and other factors of charting I had not taken into such deep account before. ... this book helped me understand how much more charting, other than SOAP's, must be completed for compliance standards. I feel this book is for just about everyone who is learning to chart as a reimbursable provider. --D. Conley