DOCUMENTATION AND HEALTHCARE COMPLIANCE: A Practical Guide to Accurate Clinical Records, HIPAA, Coding Integrity, Risk Management, Auditing, and Regulatory Readiness

Turn every patient record into evidence of safer care, stronger accountability, and a more defensible compliance program.
Documentation and Healthcare Compliance brings the major documentation and compliance responsibilities of modern healthcare into one practical professional reference. Written for health information professionals, nurses, clinicians, coding and CDI teams, privacy and security personnel, risk managers, administrators, and compliance staff, it connects day-to-day recordkeeping with the legal, financial, technological, and patient-safety consequences that follow.
Inside, you will learn how to:

• Strengthen record quality by improving authorship, timeliness, corrections, authentication, reconciliation, and closed-loop follow-up.
• Navigate privacy and security responsibilities involving protected information, patient rights, permitted disclosures, breach response, cybersecurity, mobile devices, cloud services, and remote work.
• Connect documentation to reimbursement through medical necessity, coding support, provider queries, revenue integrity, denials, overpayments, and fraud-and-abuse controls.
• Prepare for surveys and investigations with practical approaches to accreditation readiness, tracer reviews, auditing, evidence preservation, corrective action, and sustainable remediation.
• Build stronger governance for retention, legal holds, incident reporting, risk management, workforce competency, and specialized healthcare settings.
• Understand EHR and interoperability risks involving metadata, audit trails, patient portals, information blocking, data provenance, system migration, and vendor accountability.
• Evaluate emerging technology responsibly, including artificial intelligence, ambient documentation, predictive systems, model oversight, fairness, cybersecurity, and continuous assurance.