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Guide to Clinical Documentation is written by Debra Sullivan and published by F.A. Davis. It's available with International Standard Book Number or ISBN identification 0803629974 (ISBN 10) and 9780803629974 (ISBN 13).
Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.