Documentation for Health Records

Documentation for Health Records
3rd Ed.
2025 © AHIMA Press
Dilhari DeAlmeida, PhD, RHIA, FAHIMA; Heather Merkley, DHSc, RHIA
ISBN-13: 978-1-58426-970-0
eISBN-13: 978-1-58426-971-7
Healthcare Informatics, Allied Health, Patient Safety and Quality Improvement

Description

Documentation for Health Records explains the importance of accurate and timely health record documentation and addresses fundamental documentation requirements and practices in a variety of healthcare settings.

This third edition takes a fresh perspective on a variety of health record documentation uses and settings while addressing key documentation topics such as privacy and security, enterprise data and information management, telehealth, and artificial intelligence.

Key Features

  • • New chapter dedicated to behavioral healthcare documentation
  • • Provides federal and state requirements and accreditation guidelines
  • • Incorporates documentation for acute care as the practice model
  • • Covers documentation in a variety of practice settings and telehealth

Table of Contents


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