Guide to Clinical Documentation

Guide to Clinical Documentation

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Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.SOAP Note Analysisa€”Sandra Harris Below is a SOAP note for patient Sandra Harris. ... The SOAP note was written by jason Wilson, a physician assistant student who is on a rotation at the urgent care ... Pt denies diarrhea or constipation.


Title:Guide to Clinical Documentation
Author: Debra Sullivan
Publisher:F.A. Davis - 2011-12-22
ISBN-13:

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