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Introduction

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Documentation is an important part of the care given to every patient. Before a new professional can begin to write patient care notes, some essential information is needed. Part II provides the background information that is needed to begin the process of learning to document patient care. Chapter 6 discusses the important purposes of documentation and some basic guidelines that all practitioners should follow when writing in a health record. Chapter 7 gives an overview of documentation and the differences and similarities between the two types of patient care notes presented in this text.

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Chapter 8 is a brief review of medical terminology, and Chapter 9 discusses using abbreviations and includes a list of abbreviations to be used for all of the worksheets in this text. Chapter 10 discusses documentation using the International Classification of Functioning, Disability and Health (ICF) codes.

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