Test Bank for Guide to Clinical Documentation 3rd
Edition by Debra D Sullivan
GUIDE TO
Clinical
Documentation
THIRD EDITION
Debra D. Sullivan, PhD, RN, PA-C
Lead Advanced Practice Provider
Academic Urology and Urogynecology of Arizona
Litchfield Park, AZ
Owner, Sullivan Consulting Services
Medicolegal Consulting
Glendale, AZ
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2019 by F. A. Davis Company
Copyright © 2019 by F. A. Davis Company. All rights reserved. Łis product is protected by copyright. No part of it may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,
without written permission from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
,Senior Acquisitions Editor: Melissa A. Duffield
Director of Content Development: George W. Lang
Developmental Editor: Stephanie Kelly
Art and Design Manager: Carolyn O’Brien
Content Project Manager: Megan Suermann
As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo
changes. Łe author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted
standards at the time of publication. Łe author(s), editors, and publisher are not responsible for errors or omissions or for consequences
from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in
this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that
may apply in each situation. Łe reader is advised always to check product information (package inserts) for changes and new information
regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered
drugs.
Library of Congress Cataloging-in-Publication Data
Names: Sullivan, Debra D., author.
Title: Guide to clinical documentation/Debra D. Sullivan.
Description: Łird edition. | Philadelphia: F.A. Davis Company, [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2018019472 (print) | LCCN 2018019898 (ebook) | ISBN
9780803669994 | ISBN 9780803666627 (pbk.)
Subjects: | MESH: Forms and Records Control--methods | Medical
Records--standards
Classification: LCC R697.P45 (ebook) | LCC R697.P45 (print) | NLM W 80 | DDC
651.5/04261--dc23
LC record available at https://lccn.loc.gov/2018019472
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis
Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25
per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy
license by CCC, a separate system of payment has been arranged. Łe fee code for users of the Transactional Reporting Service is:
978-0-8036-6662-7/18 0 + $.25.
When I think back to 2004, when the first edition of this book
was published, I think of a wonderful group of friends who
were there to celebrate with me. As I anticipate the publication
of the third edition, almost all of those same wonderful friends
are still here, encouraging and supporting me, and cheering me
on to the finish line. Sadly, my dear friend Candy left us much
too soon, and I miss her sweet presence more than words can
say. 7e essence of her heart and soul is with me always. For
the remaining STUB-C friends (Kent, Donna, Paige, Jeff,
John, Brianna, Justin, Tim, Carla, and Jeff ), thanks for your
friendship, your love, and your constancy in my life through
the past two decades. I couldn’t ask for a better group of people
to share life with! I hope there are many more decades to come!
Not only have I been blessed with these incredible friends, but
I am fortunate to have the most loving, caring, and supportive
husband any woman could hope for. Greg is an unwavering
,source of encouragement and inspires and challenges me to be
the best I can be. He has stood beside me without complaint
through the days of writer’s block, looming deadlines,
malfunctioning computers, and the often-self-imposed frenzy
of my world. He has the insight to know when to cheer me on,
when to make me take a break, and when to give me space. I
am so grateful for his calming influence, his ability to make
me laugh and not take myself too seriously, and all he does
to keep things running smoothly in the Sullivan household.
7anks, Greg, for all this, and so much more. And I promise...
no fourth edition!
Part 1: Foundations of Documentation
Chapter 1 Medicolegal Principles of Documentation 1
Chapter 2 The Comprehensive History and Physical Examination 23
Chapter 3 SOAP Notes 45
Part II: Documentation Related to Outpatient Care
Chapter 4 Documenting Prenatal Care and Perinatal Events 79
Chapter 5 Pediatric Preventive Care Visits 93
Chapter 6 Adult Preventive Care Visits 125
, Brief Contents
Chapter 7 Older Adult Preventive Care Visits 153
Chapter 8 Outpatient Charting and Communication 173
Chapter 9 Prescription Writing and Electronic Prescribing 195
Part III: Documentation Related to Inpatient Care
Chapter 10 Admitting a Patient to the Hospital 217
Chapter 11 Documenting Inpatient Care 257
Chapter 12 Discharging Patients from the Hospital 285
Appendices
Appendix A Document Library 309
Appendix B A Guide to Sexual History Taking 373
Appendix C ISMP’s List of Error-Prone Abbreviations, Symbols,
and Dose Designations 375
Bibliography 377
Index 387
Part 1: Foundations of Documentation
Chapter 1 Medicolegal Principles of Documentation 1
Learning Outcomes 1
Introduction 1
Medical Considerations of Documentation 2
Legal Considerations of Documentation 2
Other Purposes of Documentation 3
General Principles of Documentation 3
Medical Coding and Billing 5
Copyright © 2019 by F. A. Davis Company. All rights reserved. iii
Edition by Debra D Sullivan
GUIDE TO
Clinical
Documentation
THIRD EDITION
Debra D. Sullivan, PhD, RN, PA-C
Lead Advanced Practice Provider
Academic Urology and Urogynecology of Arizona
Litchfield Park, AZ
Owner, Sullivan Consulting Services
Medicolegal Consulting
Glendale, AZ
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2019 by F. A. Davis Company
Copyright © 2019 by F. A. Davis Company. All rights reserved. Łis product is protected by copyright. No part of it may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,
without written permission from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
,Senior Acquisitions Editor: Melissa A. Duffield
Director of Content Development: George W. Lang
Developmental Editor: Stephanie Kelly
Art and Design Manager: Carolyn O’Brien
Content Project Manager: Megan Suermann
As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo
changes. Łe author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted
standards at the time of publication. Łe author(s), editors, and publisher are not responsible for errors or omissions or for consequences
from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in
this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that
may apply in each situation. Łe reader is advised always to check product information (package inserts) for changes and new information
regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered
drugs.
Library of Congress Cataloging-in-Publication Data
Names: Sullivan, Debra D., author.
Title: Guide to clinical documentation/Debra D. Sullivan.
Description: Łird edition. | Philadelphia: F.A. Davis Company, [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2018019472 (print) | LCCN 2018019898 (ebook) | ISBN
9780803669994 | ISBN 9780803666627 (pbk.)
Subjects: | MESH: Forms and Records Control--methods | Medical
Records--standards
Classification: LCC R697.P45 (ebook) | LCC R697.P45 (print) | NLM W 80 | DDC
651.5/04261--dc23
LC record available at https://lccn.loc.gov/2018019472
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis
Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25
per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy
license by CCC, a separate system of payment has been arranged. Łe fee code for users of the Transactional Reporting Service is:
978-0-8036-6662-7/18 0 + $.25.
When I think back to 2004, when the first edition of this book
was published, I think of a wonderful group of friends who
were there to celebrate with me. As I anticipate the publication
of the third edition, almost all of those same wonderful friends
are still here, encouraging and supporting me, and cheering me
on to the finish line. Sadly, my dear friend Candy left us much
too soon, and I miss her sweet presence more than words can
say. 7e essence of her heart and soul is with me always. For
the remaining STUB-C friends (Kent, Donna, Paige, Jeff,
John, Brianna, Justin, Tim, Carla, and Jeff ), thanks for your
friendship, your love, and your constancy in my life through
the past two decades. I couldn’t ask for a better group of people
to share life with! I hope there are many more decades to come!
Not only have I been blessed with these incredible friends, but
I am fortunate to have the most loving, caring, and supportive
husband any woman could hope for. Greg is an unwavering
,source of encouragement and inspires and challenges me to be
the best I can be. He has stood beside me without complaint
through the days of writer’s block, looming deadlines,
malfunctioning computers, and the often-self-imposed frenzy
of my world. He has the insight to know when to cheer me on,
when to make me take a break, and when to give me space. I
am so grateful for his calming influence, his ability to make
me laugh and not take myself too seriously, and all he does
to keep things running smoothly in the Sullivan household.
7anks, Greg, for all this, and so much more. And I promise...
no fourth edition!
Part 1: Foundations of Documentation
Chapter 1 Medicolegal Principles of Documentation 1
Chapter 2 The Comprehensive History and Physical Examination 23
Chapter 3 SOAP Notes 45
Part II: Documentation Related to Outpatient Care
Chapter 4 Documenting Prenatal Care and Perinatal Events 79
Chapter 5 Pediatric Preventive Care Visits 93
Chapter 6 Adult Preventive Care Visits 125
, Brief Contents
Chapter 7 Older Adult Preventive Care Visits 153
Chapter 8 Outpatient Charting and Communication 173
Chapter 9 Prescription Writing and Electronic Prescribing 195
Part III: Documentation Related to Inpatient Care
Chapter 10 Admitting a Patient to the Hospital 217
Chapter 11 Documenting Inpatient Care 257
Chapter 12 Discharging Patients from the Hospital 285
Appendices
Appendix A Document Library 309
Appendix B A Guide to Sexual History Taking 373
Appendix C ISMP’s List of Error-Prone Abbreviations, Symbols,
and Dose Designations 375
Bibliography 377
Index 387
Part 1: Foundations of Documentation
Chapter 1 Medicolegal Principles of Documentation 1
Learning Outcomes 1
Introduction 1
Medical Considerations of Documentation 2
Legal Considerations of Documentation 2
Other Purposes of Documentation 3
General Principles of Documentation 3
Medical Coding and Billing 5
Copyright © 2019 by F. A. Davis Company. All rights reserved. iii
