What Are Clinical Notes
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The Counselor's Steps for Progress Notes
Author: Rhonda Sutton
language: en
Publisher: Createspace Independent Publishing Platform
Release Date: 2015-06-21
Dr. Rhonda Sutton's second edition of the straightforward guide to progress notes includes additional examples, information, documentation, and clinical language that expands on the utility and readability of the first book. Additional case studies provide examples of how to use the STEPs to format notes. New chapters include information on clinical language and documentation. This book covers everything about progress notes, from how to write them, to how to store them, and even what to do when someone requests to them. In addition, clinical terms and abbreviations are included as well as suggestions for other clinical documentation such as termination letters, privacy statements, and professional disclosure statements. Suited for all types of mental health clinicians, this book will help therapists improve upon their progress notes and other forms of clinical documentation.
Clinical Text Mining
This open access book describes the results of natural language processing and machine learning methods applied to clinical text from electronic patient records. It is divided into twelve chapters. Chapters 1-4 discuss the history and background of the original paper-based patient records, their purpose, and how they are written and structured. These initial chapters do not require any technical or medical background knowledge. The remaining eight chapters are more technical in nature and describe various medical classifications and terminologies such as ICD diagnosis codes, SNOMED CT, MeSH, UMLS, and ATC. Chapters 5-10 cover basic tools for natural language processing and information retrieval, and how to apply them to clinical text. The difference between rule-based and machine learning-based methods, as well as between supervised and unsupervised machine learning methods, are also explained. Next, ethical concerns regarding the use of sensitive patient records for research purposes are discussed, including methods for de-identifying electronic patient records and safely storing patient records. The book’s closing chapters present a number of applications in clinical text mining and summarise the lessons learned from the previous chapters. The book provides a comprehensive overview of technical issues arising in clinical text mining, and offers a valuable guide for advanced students in health informatics, computational linguistics, and information retrieval, and for researchers entering these fields.
Writing Patient/Client Notes
Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model.