,Test Bank for Guide to Clinical Documentation 3rd Ed
M M M M M M M M
tion by Debra D Sullivan
M M M M
GUIDE TO
Clinical Documenta
M
M
tion
TH IRD E D I T I O N
M MM M M M M M M M M
Debra D. Sullivan, PhD, RN, PA-C
M M M M M
LeadM AdvancedM PracticeM Provider
AcademicMUrology M andMUrogynecology M ofMArizona M
LitchfieldMPark,MAZ
Owner,MSullivanM ConsultingM Services M M
edicolegalMConsulting
Glendale,M AZ
,F.MA.MDavisMCompany
M1915MArchMStreet
Philadelphia,MPAM1910
3Mwww.fadavis.com
CopyrightM ©M 2019M byM F.MA.MDavisM Company
Copyright M©M2019 MbyMF.MA.MDavisMCompany.MAllMrightsMreserved.MŁisMproductMisMprotectedMbyMcopyright. MNoMpartMofMitMmayMb
eMreproduced,Mstored MinMaMretrievalMsystem,MorMtransmittedMinMany MformMorMby Many Mmeans,Melectronic, Mmechanical,Mphotocopying
,Mrecording, MorMotherwise,MwithoutMwrittenMpermissionMfromMtheMpublisher.
Printed MinMtheMUnitedMStatesMofMAmerica
LastMdigitMindicatesMprintMnumber:M10M9 M8M7 M6M5M4M3 M2M1
SeniorMAcquisitionsMEditor:MMelissaMA.MDuffieldMDir
ectorMofMContentMDevelopment:MGeorgeMW.MLangMDeve
lopmentalMEditor:MStephanieMKelly
ArtMandMDesignMManager:MCarolynM O’Brien
ContentMProjectMManager:MMeganMSuermann
AsMnewMscientificMinformationMbecomesMavailableMthroughMbasicMandMclinicalMresearch,MrecommendedMtreatmentsMandMdrugMtherapies
MundergoMchanges.MŁeMauthor(s)MandMpublisherMhaveMdoneMeverythingMpossibleMtoMmakeMthisMbookMaccurate,MupMtoMdate,MandMinMacc
ordMwithMacceptedMstandardsMatMtheMtimeMofMpublication.MŁeMauthor(s),Meditors,MandMpublisherMareMnotMresponsibleMforMerrorsMorMomi
ssionsMorMforMconsequencesMfromMapplicationMofMtheMbook,MandMmakeMnoMwarranty,MexpressedMorMimplied,MinMregardMtoMtheMcontents
MofMtheMbook.MAnyMpracticeMdescribedMinMthisMbookMshouldMbeMappliedMbyMtheMreaderMinMaccordanceMwithMprofessionalMstandardsMofM
careMusedMinMregardMtoMtheMuniqueMcircumstancesMthatMmayMapplyMinMeachMsituation.MŁeMreaderMisMadvisedMalwaysMtoMcheckMproduct
MinformationM(packageMinserts)MforMchangesMandMnewMinformationMregardingMdoseMandMcontraindicationsMbeforeMadministeringManyMdr
ug.MCautionMisMespeciallyMurgedMwhenMusingMnewMorMinfrequentlyMorderedMdrugs.
LibraryM ofM CongressM Cataloging-in-PublicationM Data
Names:M Sullivan,MDebraM D.,Mauthor.
Title:M GuideM toM clinicalM documentation/DebraM D.MSullivan.
Description:MŁirdMedition.M|MPhiladelphia:MF.A.MDavisMCompany,M[2019]M|
MIncludes Mbibliographical Mreferences Mand Mindex.
Identifiers:MLCCNM2018019472M(print)M|MLCCNM2018019898M(ebook)M|MISBNM978080
3669994M|MISBNM9780803666627 M(pbk.)
Subjects:M|MMESH:MFormsMandMRecordsMControl--
methodsM|MMedicalMRecords--standards
Classification:MLCCMR697.P45M(ebook)M|MLCCMR697.P45M(print)M|MNLMMWM80M|
MDDC M651.5/04261--dc23
LCM recordM availableM atM https://lccn.loc.gov/2018019472
AuthorizationMtoMphotocopyMitemsMforMinternalMorMpersonalMuse,MorMtheMinternalMorMpersonalMuseMofMspecificMclients,MisMgrantedMbyMF
.MA.MDavisMCompanyMforMusersMregisteredMwithMtheMCopyrightMClearanceMCenterM(CCC)MTransactionalMReportingMService,MprovidedMt
hatMtheMfeeMofM$.25MperMcopyMisMpaidMdirectlyMtoMCCC,M222MRosewoodMDrive,MDanvers,MMAM01923.MForMthoseMorganizationsMthatMh
aveMbeenMgrantedMaMphotocopyMlicenseMbyMCCC,MaMseparateMsystemMofMpaymentMhasMbeenMarranged.MŁeMfeeMcodeMforMusersMofMtheM
TransactionalMReportingMServiceMis:
978-0-8036-6662-7/18M0 M+M$.25.
, Dedication
WhenMIMthinkMbackMtoM2004,MwhenMtheMfirstMeditionMofMthisMb
ookMwasMpublished,MIMthinkMofMaMwonderfulMgroupMofMfriends
whoMwereMthereMtoMcelebrateMwithMme.MAsMIManticipateMtheMpu
M
blicationMofMtheMthirdMedition,MalmostMallMofMthoseMsameMwond
erfulMfriendsMareMstillMhere,MencouragingMandMsupportingMme,Man
dMcheeringMmeMonMtoMtheMfinishMline.MSadly,MmyMdearMfriendMC
andyMleftMusMmuchMtooMsoon,MandMIMmissMherMsweetMpresenceM
moreMthanMwordsMcanMsay.M7eMessenceMofMherMheartMandMsoulM
isMwithMmeMalways.MForMtheMremainingMSTUB-
CMfriendsM(Kent,MDonna,MPaige,MJeff,MJohn,MBrianna,MJustin
,MTim,MCarla,MandMJeffM),MthanksMforMyourMfriendship,MyourMl
ove,MandMyourMconstancyMinMmyMlifeMthroughMtheMpastMtwoMde
cades.MIMcouldn’tMaskMforMaMbetterMgroupMofMpeopleMtoMshareMlifeM
with!MIMhopeMthereMareMmanyMmoreMdecadesMtoMcome!
NotMonlyMhaveMIMbeenMblessedMwithMtheseMincredibleMfriends,Mb
utMIMamMfortunateMtoMhaveMtheMmostMloving,Mcaring,MandMsupp
ortiveMhusbandManyMwomanMcouldMhopeMfor.MGregMisManMun
waveringMsourceMofMencouragementMandMinspiresMandMchallen
gesMmeMtoMbeMtheMbestMIMcanMbe.MHeMhasMstoodMbesideMmeMwith
outMcomplaintMthroughMtheMdaysMofMwriter’sMblock,MloomingMd
eadlines,MmalfunctioningMcomputers,MandMtheMoften-self-
imposedMfrenzyMofMmyMworld.MHeMhasMtheMinsightMtoMknowMwh
enMtoMcheerMmeMon,MwhenMtoMmakeMmeMtakeMaMbreak,MandMwh
enMtoMgiveMmeMspace.MIMamMsoMgratefulMforMhisMcalmingMinflu
ence,MhisMabilityMtoMmakeMmeMlaughMandMnotMtakeMmyselfMtooM
seriously,MandMallMheMdoes
toMkeepMthingsMrunningMsmoothlyMinMtheMSullivanMhousehold.
M 7anks,MGreg,MforMallMthis,MandMsoMmuchMmore.MAndMIMpromis
CopyrightM ©M 2019M byMF.MA.MDavisM Company.MAllM rightsM res iii
erved.
M M M M M M M M
tion by Debra D Sullivan
M M M M
GUIDE TO
Clinical Documenta
M
M
tion
TH IRD E D I T I O N
M MM M M M M M M M M
Debra D. Sullivan, PhD, RN, PA-C
M M M M M
LeadM AdvancedM PracticeM Provider
AcademicMUrology M andMUrogynecology M ofMArizona M
LitchfieldMPark,MAZ
Owner,MSullivanM ConsultingM Services M M
edicolegalMConsulting
Glendale,M AZ
,F.MA.MDavisMCompany
M1915MArchMStreet
Philadelphia,MPAM1910
3Mwww.fadavis.com
CopyrightM ©M 2019M byM F.MA.MDavisM Company
Copyright M©M2019 MbyMF.MA.MDavisMCompany.MAllMrightsMreserved.MŁisMproductMisMprotectedMbyMcopyright. MNoMpartMofMitMmayMb
eMreproduced,Mstored MinMaMretrievalMsystem,MorMtransmittedMinMany MformMorMby Many Mmeans,Melectronic, Mmechanical,Mphotocopying
,Mrecording, MorMotherwise,MwithoutMwrittenMpermissionMfromMtheMpublisher.
Printed MinMtheMUnitedMStatesMofMAmerica
LastMdigitMindicatesMprintMnumber:M10M9 M8M7 M6M5M4M3 M2M1
SeniorMAcquisitionsMEditor:MMelissaMA.MDuffieldMDir
ectorMofMContentMDevelopment:MGeorgeMW.MLangMDeve
lopmentalMEditor:MStephanieMKelly
ArtMandMDesignMManager:MCarolynM O’Brien
ContentMProjectMManager:MMeganMSuermann
AsMnewMscientificMinformationMbecomesMavailableMthroughMbasicMandMclinicalMresearch,MrecommendedMtreatmentsMandMdrugMtherapies
MundergoMchanges.MŁeMauthor(s)MandMpublisherMhaveMdoneMeverythingMpossibleMtoMmakeMthisMbookMaccurate,MupMtoMdate,MandMinMacc
ordMwithMacceptedMstandardsMatMtheMtimeMofMpublication.MŁeMauthor(s),Meditors,MandMpublisherMareMnotMresponsibleMforMerrorsMorMomi
ssionsMorMforMconsequencesMfromMapplicationMofMtheMbook,MandMmakeMnoMwarranty,MexpressedMorMimplied,MinMregardMtoMtheMcontents
MofMtheMbook.MAnyMpracticeMdescribedMinMthisMbookMshouldMbeMappliedMbyMtheMreaderMinMaccordanceMwithMprofessionalMstandardsMofM
careMusedMinMregardMtoMtheMuniqueMcircumstancesMthatMmayMapplyMinMeachMsituation.MŁeMreaderMisMadvisedMalwaysMtoMcheckMproduct
MinformationM(packageMinserts)MforMchangesMandMnewMinformationMregardingMdoseMandMcontraindicationsMbeforeMadministeringManyMdr
ug.MCautionMisMespeciallyMurgedMwhenMusingMnewMorMinfrequentlyMorderedMdrugs.
LibraryM ofM CongressM Cataloging-in-PublicationM Data
Names:M Sullivan,MDebraM D.,Mauthor.
Title:M GuideM toM clinicalM documentation/DebraM D.MSullivan.
Description:MŁirdMedition.M|MPhiladelphia:MF.A.MDavisMCompany,M[2019]M|
MIncludes Mbibliographical Mreferences Mand Mindex.
Identifiers:MLCCNM2018019472M(print)M|MLCCNM2018019898M(ebook)M|MISBNM978080
3669994M|MISBNM9780803666627 M(pbk.)
Subjects:M|MMESH:MFormsMandMRecordsMControl--
methodsM|MMedicalMRecords--standards
Classification:MLCCMR697.P45M(ebook)M|MLCCMR697.P45M(print)M|MNLMMWM80M|
MDDC M651.5/04261--dc23
LCM recordM availableM atM https://lccn.loc.gov/2018019472
AuthorizationMtoMphotocopyMitemsMforMinternalMorMpersonalMuse,MorMtheMinternalMorMpersonalMuseMofMspecificMclients,MisMgrantedMbyMF
.MA.MDavisMCompanyMforMusersMregisteredMwithMtheMCopyrightMClearanceMCenterM(CCC)MTransactionalMReportingMService,MprovidedMt
hatMtheMfeeMofM$.25MperMcopyMisMpaidMdirectlyMtoMCCC,M222MRosewoodMDrive,MDanvers,MMAM01923.MForMthoseMorganizationsMthatMh
aveMbeenMgrantedMaMphotocopyMlicenseMbyMCCC,MaMseparateMsystemMofMpaymentMhasMbeenMarranged.MŁeMfeeMcodeMforMusersMofMtheM
TransactionalMReportingMServiceMis:
978-0-8036-6662-7/18M0 M+M$.25.
, Dedication
WhenMIMthinkMbackMtoM2004,MwhenMtheMfirstMeditionMofMthisMb
ookMwasMpublished,MIMthinkMofMaMwonderfulMgroupMofMfriends
whoMwereMthereMtoMcelebrateMwithMme.MAsMIManticipateMtheMpu
M
blicationMofMtheMthirdMedition,MalmostMallMofMthoseMsameMwond
erfulMfriendsMareMstillMhere,MencouragingMandMsupportingMme,Man
dMcheeringMmeMonMtoMtheMfinishMline.MSadly,MmyMdearMfriendMC
andyMleftMusMmuchMtooMsoon,MandMIMmissMherMsweetMpresenceM
moreMthanMwordsMcanMsay.M7eMessenceMofMherMheartMandMsoulM
isMwithMmeMalways.MForMtheMremainingMSTUB-
CMfriendsM(Kent,MDonna,MPaige,MJeff,MJohn,MBrianna,MJustin
,MTim,MCarla,MandMJeffM),MthanksMforMyourMfriendship,MyourMl
ove,MandMyourMconstancyMinMmyMlifeMthroughMtheMpastMtwoMde
cades.MIMcouldn’tMaskMforMaMbetterMgroupMofMpeopleMtoMshareMlifeM
with!MIMhopeMthereMareMmanyMmoreMdecadesMtoMcome!
NotMonlyMhaveMIMbeenMblessedMwithMtheseMincredibleMfriends,Mb
utMIMamMfortunateMtoMhaveMtheMmostMloving,Mcaring,MandMsupp
ortiveMhusbandManyMwomanMcouldMhopeMfor.MGregMisManMun
waveringMsourceMofMencouragementMandMinspiresMandMchallen
gesMmeMtoMbeMtheMbestMIMcanMbe.MHeMhasMstoodMbesideMmeMwith
outMcomplaintMthroughMtheMdaysMofMwriter’sMblock,MloomingMd
eadlines,MmalfunctioningMcomputers,MandMtheMoften-self-
imposedMfrenzyMofMmyMworld.MHeMhasMtheMinsightMtoMknowMwh
enMtoMcheerMmeMon,MwhenMtoMmakeMmeMtakeMaMbreak,MandMwh
enMtoMgiveMmeMspace.MIMamMsoMgratefulMforMhisMcalmingMinflu
ence,MhisMabilityMtoMmakeMmeMlaughMandMnotMtakeMmyselfMtooM
seriously,MandMallMheMdoes
toMkeepMthingsMrunningMsmoothlyMinMtheMSullivanMhousehold.
M 7anks,MGreg,MforMallMthis,MandMsoMmuchMmore.MAndMIMpromis
CopyrightM ©M 2019M byMF.MA.MDavisM Company.MAllM rightsM res iii
erved.
