Documentation for Health Records

Documentation for Health Records explains the importance of accurate and timely health record documentation. This textbook addresses fundamental health record documentation requirements and practices for acute care as well as the nuances required by the ambulatory care, long-term care, home care and hospice, and behavioral care settings. Documentation for Health Records addresses issues related to both paper and electronic health records appropriate to each environment.

This book offers a practical orientation and overview of what health information management (HIM) and allied health students will encounter as they enter the healthcare profession.

New/updated in this edition

• Sample record documentation and legal health record guidelines
• New chapter on specialty healthcare settings documentation
• Accreditation and certification standards
• Applicable governmental regulations

Key Features

• Outlines basic healthcare documentation principles
• Addresses transition to electronic records
• Incorporates documentation for acute care as the practice model
• Covers documentation in ambulatory, home and hospice, behavioral, and long-term care settings
• Instructor materials include an instructor manual with answer keys and test banks, and PowerPoint slides