Product #: AB100723 ©2025
ISBN #: 978-1-58426-977-0
Category: Books
Book Type: Softcover
Publisher: AHIMA Press
Pages: Approx. 500 pages
Documentation for Health Records explains the importance of accurate and timely health record documentation and addresses fundamental documentation requirements and practices in a variety of healthcare settings.
This third edition takes a fresh perspective on a variety of health record documentation uses and settings while addressing key documentation topics such as privacy and security, enterprise data and information management, telehealth, and artificial intelligence.
- New chapter dedicated to behavioral healthcare documentation
- Provides federal and state requirements and accreditation guidelines
- Incorporates documentation for acute care as the practice model
- Covers documentation in a variety of practice settings and telehealth
Part I: Clinical Documentation and the Healthcare Delivery System
1 Healthcare Delivery
2 Clinical Documentation and the Health Record
Part II: Utilization of the Healthcare Record
3 Principal and Ancillary Functions of the Health Record
4 Documentation for Statistical Reporting and Public Health
5 Clinical Information, Nonclinical Data, and Electronic Health Record Design
6 Clinical Documentation Integrity
7 Data Analytics and the Role of Governance in Healthcare
Part III: Organization and Management of the Health Record
8 Federal and State Requirements and Accreditation Guidelines
9 Ambulatory Care Documentation, Accreditation, Liability, and Standards
10 Behavioral Healthcare
11 Post-Acute Inpatient Settings
12 Facility-Based Long-Term Care
13 Home Healthcare and Hospice Documentation, Accreditation, Liability, and Standards
14 Exploring Other Healthcare Settings
Glossary
Index
Instructor Resources include the following:
- Instructor manual
- Test bank
- Presentation slides
- Transition guide
The test bank is also available in Respondus.
Dilhari DeAlmeida, PhD, RHIA, FAHIMA, is an associate professor and vice chair of education in the HIM department at the University of Pittsburgh. Dr. DeAlmeida is also the program director of the bachelor of science in health informatics program. Dr. DeAlmeida has worked in basic science research for more than 12 years and transitioned to academia in 2012.
Heather Merkley, DHSc, RHIA, is the HIM program director and an associate professor at Weber State University in Ogden, UT. She has worked in the HIM field for 30 years, primarily as an HIM educator. Dr. Merkley also has experience in long-term care and home health consulting, and acute care experience in utilization management, research, and outpatient coding.
