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Medical record auditor: Documentation rules and rationales with exercises. Deborah J. Grider. American Medical Association; 2014. The fourth revised edition includes topics on EHRs, ICD-10 coding, health information management and other issues essential for maintaining compliance. Learn critical auditing fundamentals, read dozens of case studies, and use the checkpoint exercises to test your knowledge.
(Call No. Med Rcds 500-036 2014)
Long term care health information practice and documentation guidelines. American Health Information Management Association; 2001. These guidelines were developed by an AHIMA taskforce. They are intended for use by healthcare provider organizations and HIM professionals to provide assistance and direction in developing and maintaining health information systems that meet professionals practice standards.
(Call No. LTC 104-066)
Documentation for ambulatory care. American Health Information Management Association; 2001. he book will help you prepare for accreditation surveys, ensure your organization's regulatory compliance, allowing you to successfully deal with evolving regulatory changes, navigate your organization's compliance efforts and avoid problems such as incorrect reimbursement and costly government sanctions. Sample forms, a detailed index, Internet resources, and a list of national ambulatory care associations give you practical guidance.
(Call No. Med Rcds 500-021 2001)
Medical records chart analyzer: Documentation rules and rationales with exercises. Deborah J. Grider. American Medical Association; 2002. This book will prepare the reader to accomplish the following objectives: Understand the specifics about medical record chart requirements and the review process, review formatting and documentation of chart notes, learn to quickly analyze and summarize results for reporting and education, analyze documentation guidelines and elements required for each level of service, correctly audit the medical record using the handy tools provided, understand how to develop, implement, and monitor a quality improvement plan.
(Call No. Med Rcds 500-036)
From practice to paper – documentation for hospitals. Joint Commission Resources; 2002. The book was developed to help staff in acute care organizations effectively create and maintain documentation that supports and reflects high-quality care and organization processes. The book is intended for managers, leaders, and staff involved in documentation in accredited hospitals. The book is organized into 11 distinct chapters according to the patient and organization functions in the the CAHM.
(Call No. R M 151-091)
Satisfied patient: A guide to preventing malpractice claims by providing excellent customer service. Saxton, James W. Opus Communications & The Greeley Company; 2003. The book explains how incorporating "five-star" customer service principles into caregiving, encouraging patients to take responsibility for their care, and taking a few extra seconds to create legible, concise documentation can reduce claims while increasing patient satisfaction. The Satisfied Patient also describes a typical deposition and malpractice trial to illustrate how incorporating the above principles on the front end can strengthen your defense on the back end, should you ever see the inside of a courtroom.
(Call No. Pub Rel 579-010 2003)
Quality measures – documentation strategies to protect your facility’s reputation. Julia Hopp. Opus Communications & The Greeley Company; 2003. This informative book will help you understand how the quality measures are calculated and second help you make sure your staff understands how important these measures are because they will ultimately be the yard stick the public will use to rate the quality of care within your facility.
(Call No. LTC 104-099)
Defensive documentation for long-term care: Strategies for creating a more lawsuit-proof resident records. Tra Beicher. Opus Communications & The Greeley Company; 2003. The medical record is often where nursing homes are most vulnerable. In a lawsuit, poor documentation can be used as evidence against a facility, even if care was actually performed properly. Proper documentation, on the other hand, can be used in a facility's defense and contribute to lower insurance rates. The book explains what you should include in a resident's chart, what to avoid, how to handle documentation challenges, such as the initial assessment, adverse events, and refusal of medication/treatment/ nutritions or fluids and describes successful documentation formats.
(Call No. LTC 104-095)
Quality indicators – A practical guide to assessment and documentation. Julia Hopp. Opus Communications & The Greeley Company; 2004. Using this step-by-step guidebook, you will learn how quality indicators relate to MDS documentation, and how they affect your facility's survey, reimbursement, and resident care.
(Call No. LTC 104-072 2004)
Nursing documentation – reduce your risk of liability. HCPro, Inc.; 2004. The publication demonstrates why proper documentation is important, and the consequences of not documenting accurately and in a timely fashion
(Call No. Nursing 556-131)
Managing documentation risk: A guide for nurse managers. Patricia A. Duclos-Miller, MS, RN, CNA. HCPro, Inc.; 2004. Protect yourself and your staff nurses from being named in malpractice lawsuits by making sure your documentation is the best it can be. All nurses-from frontline to executive-need to understand what they are liable for when their nursing care is implicated in legal cases. They also need to learn strategies that will help them protect themselves while still offering the best quality of care.
(Call No. Nursing 556-120)
Documentation for acute care: Revised edition. American Health Information Management Association; 2004. The publication brings you new and established guidance so you know how to successfully develop forms and meet standards and documentation requirements. A well-documented and organized health record contributes to the quality of patient care. Whether you need to assess an existing health record, create a new record, or devise an EHR, you can use the forms and guidelines published in the book as a model. Forms include health record legalities, HIPAA requirements, rubber stamp signatures, nursing documentation, late entries, addendums and clarification, physician queries, and obstetrical and newborn documentation.
(Call No. Med Rcds 500-020 2004)
60 essential forms for long-term care documentation. Kathleen Martin. Opus Communications & The Greeley Company; 2004. The long-term care industry has historically lacked the tools to standardize proper documentation. 60 Essential Forms for Long-Term Care Documentation, is a compilation of more than 60 invaluable forms, designed to help you improve your facility's documentation methods and prepares you for state and other government surveys.
(Call No. LTC 104-103)
Mosby’s surefire documentation – how, what, and when nurses need to document. St. Louis, MO : Elsevier Mosby; 2006. Features case histories that illustrate key legal points, tips to help nurses streamline documentation, explanations of complex legal terms, and charting checklists.
(Call No. Nursing 556-138)
Hospital documentation – sample policies, procedures, and forms. Joint Commission Resources; 2006. This CD-ROM includes examples of written policies, procedures, and other forms actually used in hospitals that meet Joint Commission standards. The documents are categorized according to the chapters in the 2006 CAMH.
(Call No. Hlth Care Adm 310-097)
Clinical documentation-an essential guide for long-term care nurses. Barbara Acello. HCPro, Inc.; 2007. Struggling to create clinical documentation to describe residents' conditions every day? Poor clinical documentation can significantly affect survey results, reimbursement received, and most importantly, resident care. And improper documentation in the medical record has landed plenty of facilities in hot water when used as evidence in a lawsuit. Document your residents' care confidently, with an expert resource by your side. You'll not only save time, but achieve accurate, comprehensive documentation for every resident in your care.
(Call No. LTC 104-123)
A practical guide to documentation in behavioral health care. Joint Commission Resources; 2008. Updated to include the latest information in documenting behavioral health care treatment in a wide variety of settings, the book emphasizes the need for supportive documentation in behavioral health care settings and examines documentation's role in meeting clinical and management needs. A companion CD-ROM includes a wide array of interactive forms for use in your behavioral health care organization. This new edition is written for behavioral health care leaders and staff who want to improve their documentation skills. After reading this material, providers will recognize that weak documentation is a waste of valuable time and does nothing to improve care, treatment, or service. Examples of effective documentation skills are included and analyzed in all three sections of the book.
(Call No. Psych 133-056 2008)
Medical record auditor: Documentation rules and rationales with exercises. Deborah J. Grider. American Medical Association; 2010. The second edition expands on the principles of medical record documentation and instructions on how to conduct a medical record audit in the physician's or outpatient office. This resource teaches the reader to review documentation basics and format chart notes, and gives guidelines and elements required for each level of service. Tools are provided to aid in properly auditing medical records, as well as instruction on analyzing and reporting results of an audit. Application exercises and a final examination are included to test the reader's comprehension of the material. New to this edition: CD-ROM containing all of the answers to the exercises, audit tools and report templates, auditing cases divided by specialty and PowerPoint presentations with summaries from each chapter, extensive coverage of E/M documentation and chart audits, guidelines for auditing radiology and operating room records, and, information on how to ensure medical records are compliant with current regulations.
(Call No. Med Rcds 500-036 2010)