• Theory and practical review questions (located at the end of each chapter) focus on recalling important chapter information and application of codes.
• A step-by-step approach makes it easier to build your coding skills and remember the material.
• Learning objective and glossary review questions reinforce your understanding of key chapter concepts and terms.
• Coverage reflects the latest CPT E/M guidelines changes for office and other outpatient codes.
• 30-day trial to TruCode^(R) Encoder Essentials gives you experience with using an encoder (plus access to additional encoder practice exercises on the Evolve website).
• UNIQUE! Real-life coding reports simulate the reports you will encounter as a coder and help you apply coding principles to actual cases.
• Online activities on Evolve provide extra practice with assignments, including coding reports.
• More than 450 illustrations help you understand the types of medical conditions and procedures being coded, and include examples taken directly from Elsevier's professional ICD-10 and HCPCS manuals.
• UNIQUE! Four coding-question variations - covering both single-code questions and multiple-code questions and scenarios - develop your coding ability and critical thinking skills.
• UNIQUE! Coders' Index in the back of the book makes it easy to quickly locate specific codes.
• Official Guidelines for Coding and Reporting boxes show the official guidelines wording for inpatient and outpatient coding alongside in-text explanations.
• Exercises, Quick Checks, and Toolbox features reinforce coding rules and concepts, and emphasize key information.
• Valuable tips and advice are offered in features such as From the Trenches, Coding Shots, Stop!, Caution!, Check This Out, and CMS Rules.
• Sample EHR screenshots (in Appendix D) show examples similar to the electronic health records you will encounter in the workplace.

• NEW! Updated content includes the latest coding information available.
• UNIQUE! 100 real-world coding reports provide experience with reports similar to those you will encounter in practice.
• Theory exercises include fill-in-the-blank, multiple choice, and true or false questions.
• Practical exercises offer additional practice with line coding.
• Coding answer format mirrors that of Buck's main text (including icons to indicate when the learner must determine the number of codes to assign).
• Answers to odd-numbered questions are included in Appendix B, allowing you to check your accuracy.

2021 Reprint of the 1930 Edition. Illustrated. The Ebers Papyrus, also known as Papyrus Ebers, is an Egyptian medical papyrus of herbal knowledge dating to circa 1550 BC. Among the oldest and most important medical papyri of ancient Egypt, it was purchased at Luxor in the winter of 1873-74 by Georg Ebers. It is currently kept at the library of the University of Leipzig, in Germany. The Ebers Papyrus is written in hieratic Egyptian writing and represents the most extensive and best-preserved record of ancient Egyptian medicine known. The scroll contains some 700 magical formulas and folk remedies. It contains many incantations meant to turn away disease-causing demons and there is also evidence of a long tradition of empiricism. The papyrus contains a treatise on the heart. It notes that the heart is the center of the blood supply, with vessels attached for every member of the body. Mental disorders are detailed in a chapter of the papyrus called the Book of Hearts. Disorders such as depression and dementia are covered. The descriptions of these disorders suggest that Egyptians conceived of mental and physical diseases in much the same way. The papyrus contains chapters on contraception, diagnosis of pregnancy and other gynecological matters, intestinal disease and parasites, eye and skin problems, dentistry and the surgical treatment of abscesses and tumors, bone-setting and burns. The channel theory was prevalent at the time of writing of the Ebers papyrus; it suggested that unimpeded flow of bodily fluids is a prerequisite for good health. It may be a considered a precursor of ancient Greek humoral pathology and the subsequently established theory of the four humors, providing a historical connection between Ancient Egypt, ancient Greece, and medieval medicine.

• NEW! Updated content provides the latest on ICD-10 terminology and categorization.
• NEW! Summary list of CPT-4 and HCPCS codes at the beginning of each chapter introduces the appearance of different coding systems with chapter-appropriate examples.
• NEW! Context Matters! boxes help you avoid potentially embarrassing and costly coding errors by pointing out word parts, terms, and abbreviations that are spelled the same but have completely different meanings.
• NEW! CDI Alert! boxes offer a preview of how the Clinical Documentation Improvement process is related to specific medical terminology in a given body system.
• NEW! Expanded information on subcellular structures explains how gene editing may be used to treat congenital diseases.
• UNIQUE! Combination of A&P coverage with the latest medical terminology provides everything you need to know to code in ICD-10-CM, ICD-10-PCS, and CPT.
• More than 400 illustrations bring medical terminology to life with anatomic, pathologic, and procedural images.
• Pathology terms are organized by ICD-10 disease and disorder categories, allowing you to learn terms in the same order they are presented in the coding manual.
• Body Part Key provides a complete list of body parts and how they should be coded in ICD-10.
• Sample electronic medical records present terminology as you will encounter it on the job.
• Summary tables show procedural suffixes and their corresponding ICD-10 root operations.
• Practical appendices cover topics such as pharmacology, oncology, and infectious disease, providing the basic information coders need to be able to understand these ICD-10 subjects and to code them correctly.
• Evolve website provides practice and review with medical animations, labeling activities, quizzes and exams, flashcards, and the Body Spectrum electronic coloring book.

• NEW! Updated 2025 Official Code set reflects the latest ICD-10 codes needed for diagnosis coding.
• At-a-glance Guide to the 2025 ICD-10-CM Updates in the front of the book lists all new, revised, and deleted codes, providing quick lookup of the coding changes.
• Official Guidelines for Coding and Reporting (OGCRs) are listed in full in the Introduction, at the beginning of each chapter, and integrated within the code set, providing easier reference to coding rules when they are needed most.
• Unique! Full-color anatomy plates (including Netter's Anatomy art) are included in a separate section for easy reference and cross-referenced within the Tabular List of Diseases and Injuries, to help you understand anatomy and how it may affect choosing codes.
• Full-color design includes consistent color-coded symbols and text, providing easier access to codes and coding information.
• American Hospital Association's Coding Clinic^(R) citations include official ICD-10-CM coding advice relating to specific codes and their usage.
• More than 190 illustrations provide visual orientation and enhance understanding of specific coding situations.
• Items are included throughout the Tabular List to ensure accurate coding, providing additional information on common diseases and conditions.
• Additional elements within specific codes define terms and add coding instructions relating to difficult terminology, diseases and conditions, or coding in a specific category.
• Symbols and highlights draw attention to codes that may require special consideration before coding, including:
  • New, Revised, and Deleted
  • Unacceptable Principal Diagnosis
  • Codes that Call for the Use of Additional Character(s)
  • Includes, Excludes 1, and Excludes 2
  • Use Additional
  • Code First and Code Also
• Placeholder X symbol reminds users to assign placeholder X for codes less than 6 characters that require a 7th character.
• Manifestation code symbol identifies conditions for which it is important to record both the etiology and the symptom of the disease.
• HCC symbol indicates diagnoses in the Tabular List associated with Hierarchical Condition Categories.
• Age and Sex edits from the Definition of Medicare Code Edits help to ensure accuracy by denoting codes that are used only with patients of a specific age or sex.

Understand the when, why, and how! Here's your guide to developing the skills you need to master the increasing complex challenges of documenting patient care. Step by step, a straightforward 'how-to' approach teaches you how to write SOAP notes, document patient care in office and hospital settings, and write prescriptions. You'll find a wealth of examples, exercises, and instructions that make every point clear and easy to understand.

See what practitioners and students are saying online...

Definitely worth the purchase.This is a guide which will stay with you during your whole nursing program...so do not rent you must buy it and think of it as a documentation bible!--Barbie

Great resource for NP/PA school.Purchased this for my NP program. The book made writing SOAP notes and H&Ps very simple! Would recommend as a great resource--Dr. Jon

Love this! Right down to it charting instructions and guidance. Even discusses codes and other factors of charting I had not taken into such deep account before. ... this book helped me understand how much more charting, other than SOAP's, must be completed for compliance standards. I feel this book is for just about everyone who is learning to chart as a reimbursable provider. --D. Conley

Unlock the power of your brain with Brain Reset: 7 Steps to a Healthier Brain and discover the path to a healthier and happier life. This book will help you take control of your life and eliminate the symptoms of an unhealthy brain, such as chronic fatigue, light/sound sensitivity, brain fog, depression, poor concentration, and more. With simple steps and easy-to-understand language, this book will show you how to take control of your life and reset your brain for a happier and healthier future.

This health record tracker provides a handy way to log and monitor your vital health stats like blood pressure, weight, pulse, blood sugar plus a bonus doctor's visit log. Say so long to scrape pieces of paper scattered everywhere as this journal gives you one ideal place to document all your important health readings.

Inside you'll find:

• 52 weekly spreads to record and track your readings
• Doctor's visit record list
• Sections to record notes

Find other cover designs and more trackers by simply clicking on our author name.

Perfect for

• Personal daily tracker
• Individuals newly diagnosed with hypertension or diabetes
• Gifts for health-conscious friends and family members

You can be an excellent nurse in the clinical setting and still fail to prove that you are an excellent nurse if your documentation is inadequate.

Having worked in a variety of inpatient and outpatient settings, I understand the obstacles nurses face. There's just not time, nor do nurses have the mental energy to meticulously document every little thing on top of the rest of their to-do list. That's part of why I became passionate about documentation education. It doesn't have to be an overwhelming, endless challenge to chart exhaustively in hopes that you enter enough data into the chart to defend yourself one day. Rather, leveraging the most critical data, knowing how to format notes and exactly what to say, and when to spend five minutes dumping information into the chart can be learned skills that make documentation faster, easier, and less stressful, while doing a better job of defending your actions.

1. The Importance of Documentation & Overcoming Obstacles
   • Purpose(s) of Documentation
   • Defensive Charting
   • Obstacles Impacting Quality of Medical Record
   • Overcoming Obstacles
2. Legal Responsibilities of the Nurse
   • Duties of the Nurse
   • Nurse Practice Acts
   • Duties of the Hospital
   • Hospital Policy vs. State Board of Nursing Regulations
   • Reasonable Prudence
3. Failure to Fulfill (Document) Responsibilities
   • Fulfilling Responsibilities vs. Documenting Responsibilities
   • What if Responsibilities Aren't Fulfilled?
   • Mistakes Happen
   • Professional Liability Insurance
   • Malpractice
   • Medical Negligence
   • Acting with Malice
   • Fraud
   • What Happens When a Nurse is Charged with Malpractice?
   • What to Do if You Receive Notification of a Claim
4. Common Charting Mistakes & How to Avoid Them
   • The Most Common Errors
   • Charting By Exception & Charting to Capture Minimal Data
   • But I've Always Charted This Way, and Nothing Bad Has Happened Yet...
5. What You Should Be Charting
   • How and What to Chart
   • Quick Glance Charting Checklists
   • What is a Timely Manner?
   • Documenting Assessments
   • Sample Focused Assessment Criteria
   • Sharing the Responsibility
   • Modifying Electronic Data
   • Abbreviations
   • Standing Orders
   • Early Warning Systems Scores & Scales
   • Informed Consent
6. Special Circumstances
   • Paper Charting
   • Writing an Incident Report
   • Patient Leaving AMA
   • Patient Threatening to Sue You
   • Identifying Patient Belongings
   • Another Member of the Team is Not Documenting Correctly
   • Restraints
   • Defective Equipment
   • Suspected Abuse
   • Patient Requesting to View Their EMR on Hospital Computer
7. Narrative Notes
   • When & How to Write Notes
   • One Note or Several Notes?
   • Daily Narrative Notes
   • Examples of Common Notes Written As-Needed
   • How to Title Narrative Notes
   • How to Format Notes
   • Using Patient Names in Notes
   • Length of Notes
   • Create a Template
8. Tips for Less Stress When Charting
9. BONUS: How I Chart on a Typical Shift