TY  - BOOK
AU  - Wong,Christopher J.
AU  - Jackson,Sara L.
ED  - SpringerLink (Online service)
TI  - The Patient-Centered Approach to Medical Note-Writing
SN  - 9783031436338
PY  - 2023///
CY  - Cham
PB  - Springer International Publishing, Imprint: Springer
KW  - Primary care (Medicine)
KW  - Primary Care Medicine
N1  - 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
N2  - 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
UR  - #gotoholdings
ER  -