Guide to clinical documentation / Debra D. Sullivan.

Medicolegal principles of documentation
The comprehensive history and physical examination
SOAP notes
Prenatal care visits and newborn physical examination
Pediatric preventive care visits
Adult preventive care visits
Older adult visits
Outpatient charting and communication
Prescription writing and electronic prescribing
Admitting a patient to the hospital
Documenting inpatient care
Discharging patients from the hospital.