Guide to Clinical Documentation 3rd Edition:
I. Foundations of Documentation
1. Medicolegal Principles of Documentation
2. The Comprehensive History and Physical Examination
3. SOAP Notes
II. Documentation Related to Outpatient Care
4. Prenatal Care Visits and Newborn Physical Examination
5. Pediatric Preventive Care Visits
6. Adult Preventive Care Visits
7. Older Adult Visits
8. Outpatient Charting and Communication
9. Prescription Writing and Electronic Prescribing
III. Documentation Related to Inpatient Care
10. Admitting a Patient to the Hospital
11. Documenting Inpatient Care
12. Discharging Patients from the Hospital
Appendices
A. Document Library
B. A Guide to Sexual History Taking
C. ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations
Bibliography






Dentistry
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