Documentation for Health Records

Cheryl Gregg Fahrenholz, RHIA, CCS-P, Ruthann Russo, PhD, JD, MPH, RHIT

*Please note that e-books cannot be returned

Documentation for Health Records explains the importance of accurate and timely health record documentation. This textbook addresses fundamental health record documentation requirements and practices in language understandable to the student new to the study of healthcare administration.


The book begins with the basics of documentation standards based on the acute care setting, and includes separate chapters on ambulatory care, long-term care, home care and hospice, and behavioral care settings. Documentation for Health Records addresses issues related to both paper and electronic health records appropriate to each environment.


Key Features

  • Sample paper forms
  • EHR screen shots
  • Accreditation and certification standards
  • Applicable governmental regulations


About the Authors

Cheryl Gregg Fahrenholz, RHIA, CCS-P, is the president of Preferred Healthcare Solutions. She has more than 25 years of experience working with many aspects of health information management, including documentation and coding audits, electronic health record selection and implementation, and charge description master reviews.

Ruthann Russo, PhD, JD, MPH, RHIT, is the chief executive officer of Cimex Health and managing director with Navigant Consulting’s Healthcare Group. She has worked in a variety of areas including quality assurance, HIM, academics, and consulting.

*Please note e-books are not returnable

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There are two ways to access e-books: Download and View Online. Books downloaded to your computer do not expire and you can view online up to one year upon activation. e-books are not available to print.


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