The Patient-Centered Approach to Medical Note-Writing
Springer International Publishing (Verlag)
978-3-031-43632-1 (ISBN)
Patients are increasingly accessing their own electronic health record, ushering medical chart notes out of the cloistered purview of clinicians and into the age of transparency. With the recognition that patients are reading what is written about them, there is a need for a comprehensive reference on best practices for writing medical notes in this new era.
The Patient-Centered Approach to Medical Note-Writing covers important topics including stigmatizing language, the electronic health record, the different parts of a typical medical note, mental health, substance use, difficult encounters, and how to address electronic communication such as test results and patient messages. This book serves as a vital reference for students, residents, fellows and practicing clinicians.
Christopher Wong, MD is an Associate Professor of General Internal Medicine at the University of Washington. He is a clinician-educator in primary care, practicing medicine at the university outpatient clinic as well as teaching medical students and internal medicine residents. His academic career has focused on general medical topics, including perioperative medicine, preventive health and primary care training. He is the editor of two books with Springer: co-editor of the first edition of The Perioperative Medicine Consult Handbook (2013) and sole editor of Primary Care of the Solid Organ Transplant Recipient (2020).
Dr. Wong has been teaching students and residents on the subject of patient-centered medical notes for many years. The University of Washington was one of the early sites for the "Open Notes" project in which patients have routine access to their medical records-providers there have many years of experience working and teaching in this clinical setting.
Sara Jackson, MD, MPH, is an Associate Professor of General Internal Medicine at the University of Washington. She practices primary care in an academic outpatient clinic at Harborview Medical Center, which serves the safety-net population of King County, WA. In addition to patient care, she teaches internal medicine residents in clinic, and serves in an administrative role as Associate Medical Director for Ambulatory Clinics at Harborview. Her scholarly work in the area of health services research has focused upon women's health and equitable health care delivery. She was also involved in the original Open Notes study at UW in 2010 and has been writing and teaching about experiences with Open Notes since then.
Introduction: Why this book?.- A History of Medical Charts: Who owns it and who is it for?.- Patient-Centered Language: General Principles.- The Chief "Complaint" and History of Present Illness.- The Problem List / Medical History.- The Social History, Substance Use, and Lifestyle Habits.
| Erscheinungsdatum | 10.02.2024 |
|---|---|
| Zusatzinfo | XII, 245 p. 9 illus., 8 illus. in color. |
| Verlagsort | Cham |
| Sprache | englisch |
| Maße | 155 x 235 mm |
| Gewicht | 403 g |
| Themenwelt | Medizin / Pharmazie ► Gesundheitswesen |
| Medizin / Pharmazie ► Medizinische Fachgebiete | |
| Schlagworte | Bias • Gender • language • medical charts • note writing |
| ISBN-10 | 3-031-43632-6 / 3031436326 |
| ISBN-13 | 978-3-031-43632-1 / 9783031436321 |
| Zustand | Neuware |
| Informationen gemäß Produktsicherheitsverordnung (GPSR) | |
| Haben Sie eine Frage zum Produkt? |
aus dem Bereich
