rr rr rr rr rr rr
3rdEdition by Debra D Sullivan
rr r rr rr rr rr
GUIDE
Clinical
TO
r r
Documentatio
rr
n
TH IR D
r rr r rr r r EDIT ION
rr rr rr rr rr rr
Debra D. Sullivan, PhD, RN, PA-C
rr rr rr rr rr
Lead Advanced Practice
r r Provider r r r r
Academic Urology and Urogynecology of r r r r rr r r
Arizona Litchfield Park, AZ
rr r r r rr
Owner, Sullivan Consulting r r r r
Services Medicolegal Consulting
r r r r r
Glendale, AZ r r
,F. rrA. rrDavis rrCompany
rr1915 rr Arch rr Street
rrPhiladelphia, rrPA
rr19103rwww.fadavis.co
m
Copyright r r © rr 2019 r r by rr F. rrA. rrDavis r r Company
Copyright rr © r r 2019 r r by rr F. rrA. rrDavis rr Company. rrAll rr rights r r reserved. rrŁis rr product r r is rr protected r r by rr copyright. rrNo r r part rr of rr it r r may rr be
rr reproduced, rrstored rrin rra rrretrieval rrsystem, rror rrtransmitted rrin rrany rrform rror rrby rrany rrmeans, rrelectronic, rrmechanical, rrphotocopying,
rrrecording, rror rrotherwise,rwithout rrwritten rr permission rrfrom rr the rrpublisher.
Printed rrin rrthe rrUnited rrStates rrof rrAmerica
Last rrdigit rrindicates rrprint rrnumber: rr10 rr9 rr8 rr7 rr6 rr5 rr4 rr3 rr2 rr1
Senior rrAcquisitions rrEditor: rrMelissa rrA. rrDuffield
rrDirector rrof rr Content rrDevelopment: rr George rrW.
rrLangrDevelopmental rrEditor: rrStephanie rrKelly
Art r r and r r Design r r Manager: r r Carolyn r r O’Brien
Content rrProject rrManager: rrMegan rrSuermann
As rrnew rrscientific rrinformation rrbecomes rravailable rrthrough rrbasic rrand rrclinical rrresearch, rrrecommended rrtreatments rrand rrdrug rrtherapies
rrundergo rrchanges. rr Łe r r author(s) r r and r r publisher r r have r r done r r everything r r possible r r to r r make r r this r r book r r accurate, rr up r r to r r date, rr and r r in
r r accord r r with r r accepted rr standards r r at rr the r r time r r of r r publication. rrŁe r r author(s), rr editors, rr and r r publisher r r are r r not r r responsible rr for r r errors
r r or r r omissions r r or r r for r r consequences rr from rrapplication rrof rrthe rrbook, rrand rr make rrno rr warranty, rrexpressed rror rrimplied, rrin rrregard rr to rrthe
rrcontents rrof rrthe rrbook. rr Any rrpractice rrdescribed rrin rrthis rrbook rr should rrbe rrapplied rrby rrthe rrreader rrin rraccordance rr with rrprofessional
rrstandards rrof rrcare rrused rrin rrregard rrto rrthe rrunique rrcircumstances rrthat rr may rr apply rr in rr each rr situation. rrŁe rr reader rr is rr advised rr always rr to
rr check rr product rr information rr (package rrinserts) rr for rr changes rr and rr new rrinformation rrregarding rrdose rrand rr contraindications rrbefore
rradministering rrany rrdrug. rrCaution rris rrespecially rrurged rr when rrusing rrnew rror rrinfrequently rrordered rrdrugs.
Library rrof rrCongress rrCataloging-in-Publication rrData
Names: rr Sullivan, rrDebra r r D., rrauthor.
Title: r r Guide r r to r r clinical r r documentation/Debra r r D. rrSullivan.
Description: rrŁird rredition. rr| rrPhiladelphia: rrF.A. rrDavis rrCompany, rr[2019] rr |
rrIncludes rrbibliographical rrreferences rrand rrindex.
Identifiers: rrLCCN rr2018019472 rr(print) rr| rrLCCN rr2018019898 rr(ebook) rr|
rr ISBNr9780803669994 rr| rrISBN rr9780803666627 rr(pbk.)
Subjects: rr| rrMESH: rrForms rrand rrRecords rrControl--methods rr|
rr MedicalrR ecords--standards
Classification: rrLCC r r R697.P45 r r (ebook) rr | rr LCC rr R697.P45 r r (print) r r | rr NLM rr W rr80
rr | rr DDCr651.5/04261--dc23
LC r r record r r available r r at r r https://lccn.loc.gov/2018019472
Authorization rrto rrphotocopy rritems rrfor rrinternal rror rrpersonal rruse, rror rrthe rrinternal rror rrpersonal rruse rrof rrspecific rrclients, rris rrgranted rrby rrF. rrA.
rrDavis rrCompany rr for rrusers rrregistered r r with rrthe rrCopyright rrClearance rrCenter rr(CCC) rr Transactional rrReporting rrService, rrprovided rrthat
rrthe rrfee rrof rr$.25 rrper rrcopy rris rrpaid rrdirectly rrto rrCCC, rr222 rrRosewood rrDrive, rrDanvers, rrMA rr01923. rrFor rrthose rrorganizations rrthat rrhave
rrbeen rrgranted rra rrphotocopy rr license rrby rr CCC, rra rr separate rr system rr of rr payment rr has rrbeen rr arranged. rrŁe rr fee rr code rrfor rr users rr of rr the
rrTransactional rr Reporting rr Service rr is:
978-0-8036-6662-7/18 rr0 rr+ rr$.25.
, Dedication
When I think back to 2004, when the first edition of this
rr rr rr rr rr rr rr rr rr rr rr
rr book was published, I think of a wonderful group of
rr rr rr rr rr rr rr rr rr
rr friends who were there to celebrate with me. As I anticipate
rr rr rr rr rr rr rr rr rr rr
the publicationof the third edition, almost all of those same
rr rr r rr rr rr rr rr rr rr rr
rr wonderful friendsare still here, encouraging and supporting
rr r rr rr rr rr rr
rr me, and cheering meon to the finish line. Sadly, my dear
rr rr rr r rr rr rr rr rr rr rr
rr friend Candy left us muchtoo soon, and I miss her sweet
rr rr rr rr r rr rr rr rr rr rr
rr presence more than words can say. 7e essence of her heart
rr rr rr rr rr rr rr rr rr rr
rr and soul is with me always. For the remaining STUB-C
rr rr rr rr rr rr rr rr rr rr
rr friends (Kent, Donna, Paige, Jeff, John, Brianna, Justin,
rr rr rr rr rr rr rr
rr Tim, Carla, and Jeff ), thanks for your friendship, your
rr rr rr rr rr rr rr rr rr
rr love, and your constancy in my life through the past two
rr rr rr rr rr rr rr rr rr rr
rr decades. I couldn’t ask for a better group of people to share
rr rr rr rr rr rr rr rr rr rr rr
rr life with! I hope there are many more decades to come!
rr rr rr rr rr rr rr rr rr rr
Not only have I been blessed with these incredible friends,
rr rr rr rr rr rr rr rr rr
rr butI am fortunate to have the most loving, caring, and
r rr rr rr rr rr rr rr rr rr
rr supportivehusband any woman could hope for. Greg is an
r rr rr rr rr rr rr rr rr
rr unwavering source of encouragement and inspires and rr rr rr rr rr rr
rr challenges me to be the best I can be. He has stood beside
rr rr rr rr rr rr rr rr rr rr rr rr
rr me without complaint through the days of writer’s block,
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looming deadlines, malfunctioning computers, and the often-
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self-imposed frenzy of my world. He has the insight to know rr rr rr rr rr rr rr rr rr rr
rr when to cheer me on,when to make me take a break, and
rr rr rr rr r rr rr rr rr rr rr rr
rr when to give me space. I am so grateful for his calming
rr rr rr rr rr rr rr rr rr rr rr
rr influence, his ability to make me laugh and not take myself
rr rr rr rr rr rr rr rr rr rr
rr too seriously, and all he does
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to keep things running smoothly in the Sullivan household.
rr rr rr rr rr rr rr rr
rr 7anks, Greg, for all this, and so much more. And I
rr rr rr rr rr rr rr rr rr rr
Copyright rr © rr 2019 rrby rrF. rrA. rrDavis r r Company. rrAll rr rights iii
rr reserved.