Best Medical History & Records Books of 2025

Bates' Guide To Physical Examination and History Taking (Lippincott Connect) is a comprehensive guide for medical professionals to perform physical examinations with accuracy and efficiency. The book includes fully illustrated, step-by-step techniques and an easy-to-follow two-column format that correlates examination techniques with differential diagnoses. It also covers special populations, LGBTQ and diverse populations throughout the life cycle. The book offers clinical pearls, detailed tables of abnormal conditions, and an online glossary. The book is highly recommended for medical practitioners who want to master the art of physical examination.

The Bates' Pocket Guide to Physical Examination and History Taking (Lippincott Connect) is a trusted pocket-sized reference for medical students, PAs, pharmacy, and nursing students. The updated ninth edition provides concise, authoritative guidance on how to perform the patient interview, physical examination, and other core assessments. With an enhanced design, new content, and new student-friendly learning aids, the guide includes fully illustrated, step-by-step techniques and algorithms that provide helpful starting approaches for patients with common presenting symptoms. This book is an ideal quick-reference resource for effective information-gathering and decision-making approaches.

This book titled "Guide to Clinical Documentation" is a comprehensive guide that teaches the skills needed to document patient care. It covers how to write SOAP notes, document patient care in various settings, and write prescriptions. The book provides a straightforward approach, with plenty of examples, exercises, and instructions to make every point clear and easy to understand. It is a great resource for healthcare practitioners and students, as it simplifies writing SOAP notes and H&Ps. The book covers compliance standards and other factors of charting that practitioners need to consider. Overall, this book is a valuable resource for anyone who wants to master the complex challenges of documenting patient care.

Medical Terminology & Anatomy for Coding, 4th Edition is a comprehensive textbook that merges anatomy and physiology coverage with the latest medical terminology required by coders and coding students. It includes ICD-10 and CPT coding guidelines and notes, electronic medical records, and integrated exercises. The ICD-10-CM classification system is used to organize diseases and disorders, with well-labelled illustrations to help visualize the associated anatomy. The book also provides a new Infectious Disease Process Basics appendix that covers the terminology and physiology of infectious diseases. The updated CPT coding information and additional notes highlight connections between terminology and codes, making it an ideal reference for students and coders alike.

The Buck's Step-by-Step Medical Coding, 2023 Edition – Text and Workbook Package by Elsevier is an essential guide for medical coders. The book provides a comprehensive and detailed overview of the medical coding process, including step-by-step instructions and practical exercises. The package includes a workbook that allows readers to practice their skills and apply what they have learned. The book is well-organized, easy to understand, and includes updated information on the latest coding standards and regulations.

Medical Billing & Coding For Dummies is a comprehensive guide for anyone interested in starting a career in medical billing and coding. The book covers everything from finding the right study course to dealing with government agencies and insurance companies. It also provides insights into the latest updates to the ICD-10 and ethical and legal issues. The book is well-organized and easy to read, making it an ideal resource for beginners. Overall, Medical Billing & Coding For Dummies is an excellent resource for anyone looking to start a career in this field.

Medicare For You: A Smart Person's Guide by Diane J. Omdahl RN MS is an essential guide for anyone approaching Medicare eligibility. With over 10,000 Americans becoming eligible for Medicare every day, author Diane J. Omdahl, a true pioneer in the field of Medicare benefits, takes readers through every step of the process, ensuring they make the right decisions at the right time. This book is a must-read to avoid costly mistakes and scams and ensure that Medicare works for you. Overall, it is an excellent resource for those looking to maximize their Medicare benefits.

Buck's 2023 Step-by-Step Medical Coding is a comprehensive and practical guide to coding using all current coding sets. It offers a step-by-step approach that makes it easy to build coding skills and remember the material. The book includes practice exercises, review questions, and "real-life" coding reports that simulate the reports coders encounter in the field. Additionally, the book offers a 30-day trial to TruCode® Encoder Essentials, providing experience using an encoder and access to additional encoder practice exercises on the Evolve website. The Coders’ Index in the back of the book makes it easy to quickly locate specific codes. Overall, Buck's 2023 Step-by-Step Medical Coding is an excellent resource for anyone looking to start a career in medical coding or further their coding expertise.

Workbook for Buck's 2023 Step-by-Step Medical Coding is an excellent resource for anyone looking to improve their coding skills. The workbook contains over 1,200 exercises, including theory, practical, and reporting exercises. It also includes 100 real-world coding reports to give readers a sense of what they might encounter on the job. The exercises cover all the code sets found in the main text, including ICD-10-CM, CPT, HCPCS, and inpatient coding. The updated content reflects the latest coding information and answers to all questions are included in Appendix B. Overall, this workbook is an invaluable tool for mastering coding concepts and is highly recommended.

This book, "Nursing Narrative Note Examples to Save Your License," is a comprehensive guide for nurses to improve their charting and documentation skills. The author, an experienced RN-MSN, provides practical tips and 44 specific examples for commonly encountered situations in medical/surgical or lower acuity units. The book covers topics such as HIPAA, abbreviations, and how to phrase notes effectively. The author's relatable perspective and easy-to-read format make this book a valuable resource for nurses who want to feel confident in their charting and defend their actions. Overall, this book is an essential tool for any nurse who wants to improve their documentation skills.