Documentation for Health Records

Documentation for Health Records
  • 2nd Ed.
  • 2017
  • © AHIMA Press
  • Cheryl Gregg Fahrenholz, RHIA, CCS-P
  • ISBN-10: 1-58426-554-X / ISBN-13: 978-1-58426-554-2
  • Healthcare Informatics, Patient Safety and Quality Improvement


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Documentation for Health Records, Second Edition, explains the importance of accurate and timely health record documentation. This textbook addresses fundamental health record documentation requirements and practices a variety of healthcare settings. This new edition expands topics such as information governance, electronic health records and health IT, clinical documentation improvement, and more.

Key Features

  • • New chapters on data analytics and information governance
  • • Outlines basic healthcare documentation principles
  • • Sample record documentation and legal health record guidelines
  • • Provides updates to federal and state requirements and accreditation guidelines
  • • Specialty healthcare settings documentation
  • • Incorporates documentation for acute-care as the practice model
  • • Covers documentation in ambulatory, home health, hospice, and long-term care settings


Table of Contents


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