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
- 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
- Answer keys designated as "instructor material" are only provided to verified instructors employed at a school with an .edu address. No exceptions will be made
About the Authors
Cheryl Gregg Fahrenholz, RHIA, CCS-P, is the president of Preferred Healthcare Solutions. She has more than 25 years of experience working with many aspects of health information management, including documentation and coding audits, electronic health record selection and implementation, and charge description master reviews.
Ruthann Russo, PhD, JD, MPH, RHIT, is the chief executive officer of Cimex Health and managing director with Navigant Consulting’s Healthcare Group. She has worked in a variety of areas including quality assurance, HIM, academics, and consulting.