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A handbook for medical charting that focuses on clarity in communication, especially regarding clinical communication and medico-legal defensibility. The handbook’s main focus is how to transfer a clinician’s vision of the patient encounter into the medical chart in a clear and concise way. It discusses how to apply rules of effective writing to medical charts. It also discusses how the medical chart fits into the American medical malpractice system.
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A handbook for medical charting that focuses on clarity in communication, especially regarding clinical communication and medico-legal defensibility. The handbook’s main focus is how to transfer a clinician’s vision of the patient encounter into the medical chart in a clear and concise way. It discusses how to apply rules of effective writing to medical charts. It also discusses how the medical chart fits into the American medical malpractice system.