Dedication

v

Acknowledgments

ix

About the Authors

xi

Contributing Authors

xiii

Preface

xv

Chapter 1

Introduction to Documentation

1

Chapter 2

Basic Principles of Medical Documentation

7

Chapter 3

Types of Written Documentation

13

Chapter 4

Styles of Writing

23

Chapter 5

Legal Considerations in Documentation

31

Chapter 6

Electronic Documentation

39

Chapter 7

Documentation for Reimbursement

47

Appendix A

Board of Certification Standards of Professional Practice

53

Appendix B

Symbols and Medical Terminology Abbreviations

59

Appendix C

Worksheets for Documentation Abbreviation

81

Appendix D

Worksheets for Documentation Writing Styles

87

Appendix E

Commonly Used Forms—Information Forms

105

Appendix F

Commonly Used Forms—Privacy Forms

187

Appendix G

Commonly Used Forms—Release Forms

203

Appendix H

Commonly Used Forms—Evaluation Forms

243

Appendix I

Commonly Used Forms—Miscellaneous Forms

263

Appendix J

Commonly Used Forms—Policy Forms

283

Financial Disclosures

293

Index

295