By Nell Tharpe
This article provides A Compilation Of present Practices that incorporates Evidence-Based, conventional, And Empiric Care From a large choice Of resources. each one guide strikes via challenge identity And remedy utilizing A Standardized layout For daily medical perform With diversified Populations. the tips Are at present In Use by way of Many Practices As a manner Of assembly the yankee university Of Nurse Midwives (ACNM) innovations, And Are applicable For Collaborative perform With general practitioner Colleagues.
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Extra resources for Clinical Practice Guidelines for Midwifery & Womens Health 2006-2009
A master file should be kept of regularly used client education materials so the midwife may refer back as needed to see what materials were used during a specific time period. qxd 18 11/30/05 Chapter 2 10:42 AM Page 18 Documentation of Midwifery and Women’s Health Care should indicate whether education and support measures were provided verbally or in writing. Written instructions or recommendations allow the client to refer back to them after the visit, and refresh her memory about what happened at the visit.
S. Preventive Services Task Force [USPSTF]. ). Topic index A–Z. htm • Admission diagnosis • History of present condition or illness • Past medical history • Past surgical history • Current medications • Allergies • Social history • Family history • Review of systems • Physical findings • Diagnostic testing • Hospital course • Procedures • Complications • Discharge diagnosis • Discharge medications • Discharge instructions • Condition on discharge Summary Documentation is an essential skill for midwifery and women’s health practice that should be attended to with the same care and attention given to other components of clinical practice.
2–4). The CPT book clearly outlines the required components for evaluation of care provided. A brief overview is provided here. The E/M evaluation considers four types of history and physical exam. The problem focused visit is limited to a brief history of the reason for the encounter and an exam that is limited to the affected area. The expanded problem focused visit adds a pertinent system review and examination of additional body systems that might be affected by the presenting problem. The detailed visit adds pertinent history related to the reason for the encounter, and a thorough examination of the affected area and related organ systems.