Guide to clinical documentation

READING RESOURCES

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

 

· Chapter 4, “Vital Signs and Pain Assessment” (Previously read in Week 6)

· Chapter 22, “Musculoskeletal System” This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.

 

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

 

https://class.content.laureate.net/eba728522c691037bd67a41372ab9689.pdf

 

https://class.content.laureate.net/da4876848e2d9c91b3e92450cf87c16c.pdf

 

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

 

· Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”) (Previously read in Weeks 1, 2, 3, 4, and 5)

· Chapter 3, “SOAP Notes” This section explains the procedural knowledge needed to perform musculoskeletal procedures.

 

https://class.content.laureate.net/686bd0ae58e747ddd9370c20f45d5016.rtf

 

https://class.content.laureate.net/e4b319b3ee017929a4c6d6adb8845314.rtf

 

https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=61014994&site=ehost-live&scope=site

 

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

 

· Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682) In this chapter, the authors explain the physiology of the spine, pelvis, and extremities. The chapter also describes how to examine the spine, pelvis, and extremities.

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