NURS-6512N Guide to Clinical Documentation 3rd Edition by Debra D Sullivan

GUIDE TO Clinical Documentation T H I R D E D I T I O N 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 Copyright © 2019 by F. A. Davis Company Copyright © 2019 by F. A. Davis Company. All rights reserved. !is 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. !e 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. !e 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. !e 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: !ird edition. | Philadelphia: F.A. Davis Company, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2 (print) | LCCN 8 (ebook) | ISBN 9994 | ISBN 6627 (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 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. !e fee code for users of the Transactional Reporting Service is: 978-0-8036-6662-7/18 0 + $.25. Copyright © 2019 by F. A. Davis Company. All rights reserved. iii Dedication 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. !e 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. !anks, Greg, for all this, and so much more. And I promise... no fourth edition! Copyright © 2019 by F. A. Davis Company. All rights reserved. v Reviewers GILBERT BOISSONNEAULT, PHD, PA-C, DFAAPA Professor Division of Physician Assistant Studies Medical University of South Carolina Charleston, SC ELIZABETH BROWNLEE, MPAS, PA-C Physician Assistant, Assistant Professor School of Physician Assistant Studies, College of Medicine University of Florida Gainesville, FL RHONDA GLEN FELDMAN, MHS, MSS, PA-C Program Director Physician Assistant University of New England Portland, ME PAT KENNEY-MOORE, EDD, PA-C Associate Director/Academic Coordinator/Associate Professor School of Medicine, Division of Physician Assistant Education Oregon Health & Science University Portland, OR SARA HADDOW LIEBEL, MSA, PA-C Education Director/Associate Professor Physician Assistant Department, College of Allied Health Sciences Augusta University Augusta, GA NICOLE SCHMITZ, DNP, APRN, PNP, CHSE Assistant Professor Nursing Minnesota State University – Mankato Mankato, MN EMILY K. SHEFF, CMSRN, FNP, BC Assistant Professor School of Nursing MGH Institute of Health Professions