,GUIDE TO
Clinical
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Documentation
THIRD
bEDITION
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Debra D. Sullivan, PhD, RN, PA-C
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Lead Advanced Practice Provider
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Academic Urology and Urogynecology of
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Arizona L itchfield Park, AZ
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Owner, Sullivan Consulting
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Services M edicolegal Consulting
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Glendale, AZ bf
,F. A. Davis Company
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1915 Arch Street
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Philadelphia, PA
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19103www.fadavis.com
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Copyright © 2019 by F. A. Davis Company bf bf bf bf bf bf bf
Copyright © 2019 by F. A. Davis Company. All rights reserved. Łis product is protected by copyright. No part of it may be
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reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying,
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recording, or otherwise, without written permission from the publisher.
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Printed in the United States of America
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Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
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Senior Acquisitions Editor: Melissa A. Duffield
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Director of Content Development: George W.
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LangDevelopmental Editor: Stephanie Kelly
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Art and Design Manager: Carolyn O’Brien
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Content Project Manager: Megan Suermann
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As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies
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undergo changes. Łe author(s) and publisher have done everything possible to make this book accurate, up to date, and in
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accord with accepted standards at the time of publication. Łe author(s), editors, and publisher are not responsible for errors or
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omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents
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of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care
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used in regard to the unique circumstances that may apply in each situation. Łe reader is advised always to check product
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information (package inserts) for changes and new information regarding dose and contraindications before administering any drug.
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Caution is especially urged when using new or infrequently ordered drugs.
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Library of Congress Cataloging-in-Publication Data
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Names: Sullivan, Debra D., author. bf bf bf bf
Title: Guide to clinical documentation/Debra D. Sullivan.
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Description: Łird edition. | Philadelphia: F.A. Davis Company, [2019] bf bf bf bf bf bf bf bf
| Includes bibliographical references and index.
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Identifiers: LCCN 2018019472 (print) | LCCN 2018019898 (ebook) | bf bf bf b f bf bf bf bf
ISBN9780803669994 | ISBN 9780803666627 (pbk.)
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Subjects: | MESH: Forms and Records Control--methods | bf bf bf bf bf bf bf
MedicalRecords--standards
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Classification: LCC R697.P45 (ebook) | LCC R697.P45 (print) | NLM W 80 | bf bf bf bf bf bf bf bf bf bf bf bf
DDC651.5/04261--dc23
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LC record available at https://lccn.loc.gov/2018019472
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Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A.
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Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the
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fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
granted a photocopy license by CCC, a separate system of payment has been arranged. Łe fee code for users of the Transactional
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Reporting Service is:
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978-0-8036-6662-7/18 0 + $.25. bf bf bf
, Dedication
When I think back to 2004, when the first edition of this book
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bf was published, I think of a wonderful group of friends who
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bf were there to celebrate with me. As I anticipate the
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publicationof the third edition, almost all of those same
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bf wonderful friendsare still here, encouraging and supportingbf bf bf bf bf bf bf
bf me, and cheering meon to the finish line. Sadly, my dear
bf bf bf bf bf bf bf bf bf bf bf
bf friend Candy left us muchtoo soon, and I miss her sweet
bf bf bf bf bf bf bf bf bf bf bf
bf presence more than words can say.7e essence of her heart and
bf bf bf bf bf bf bf bf bf bf bf
bf soul is with me always. For the remaining STUB-C friends
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bf (Kent, Donna, Paige, Jeff, John, Brianna, Justin, Tim,
bf bf bf bf bf bf bf
bf Carla, and Jeff ), thanks for your friendship, your love, and
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bf your constancy in my life through the past two decades. I
bf bf bf bf bf bf bf bf bf bf
bf couldn’t ask for a better group of people to share life with! I
bf bf bf bf bf bf bf bf bf bf bf bf
bf hope there are many more decades to come!
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Not only have I been blessed with these incredible friends,
bf bf bf bf bf bf bf bf bf
bf butI am fortunate to have the most loving, caring, and
bf bf bf bf bf bf bf bf bf bf
bf supportivehusband any woman could hope for. Greg is an bf bf bf bf bf bf bf bf bf
bf unwavering source of encouragement and inspires and bf bf bf bf bf bf
bf challenges me to be the best I can be. He has stood beside bf bf bf bf bf bf bf bf bf bf bf bf
bf 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 bf bf bf bf bf bf bf bf bf bf
bf when to cheer me on, when to make me take a break, and
bf bf bf bf bf bf bf bf bf bf bf bf
bf when to give me space. I am so grateful for his calming
bf bf bf bf bf bf bf bf bf bf bf
bf influence, his ability to make bf bf bf bf
me laugh and not take myself too seriously, and all he
bf bf bf bf bf bf bf bf bf bf
bf does to keep things running smoothly in the Sullivan
bf bf bf bf bf bf bf bf
Copyright © 2019 by F. A. Davis Company. All rights
bf bf bf bf bf bf bf bf bf iii
reserved.
bf
Clinical
bf
Documentation
THIRD
bEDITION
f b
f
Debra D. Sullivan, PhD, RN, PA-C
bf b f bf bf bf
Lead Advanced Practice Provider
bf bf bf
Academic Urology and Urogynecology of
bf bf bf bf
Arizona L itchfield Park, AZ
bf b
f b f bf
Owner, Sullivan Consulting
b f b f
Services M edicolegal Consulting
b f b
f b f
Glendale, AZ bf
,F. A. Davis Company
bf bf bf
1915 Arch Street
bf bf bf
Philadelphia, PA
bf bf
19103www.fadavis.com
bf bf
Copyright © 2019 by F. A. Davis Company bf bf bf bf bf bf bf
Copyright © 2019 by F. A. Davis Company. All rights reserved. Łis product is protected by copyright. No part of it may be
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying,
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
recording, or otherwise, without written permission from the publisher.
bf bf bf bf bf bf bf bf bf
Printed in the United States of America
bf bf bf bf bf bf
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
bf bf bf bf bf bf bf bf bf bf bf bf bf bf
Senior Acquisitions Editor: Melissa A. Duffield
bf bf bf bf bf
Director of Content Development: George W.
bf bf bf bf bf bf
LangDevelopmental Editor: Stephanie Kelly
bf bf bf bf bf
Art and Design Manager: Carolyn O’Brien
bf bf bf bf b f
Content Project Manager: Megan Suermann
bf bf bf bf
As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
undergo changes. Łe author(s) and publisher have done everything possible to make this book accurate, up to date, and in
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
accord with accepted standards at the time of publication. Łe author(s), editors, and publisher are not responsible for errors or
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
used in regard to the unique circumstances that may apply in each situation. Łe reader is advised always to check product
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
information (package inserts) for changes and new information regarding dose and contraindications before administering any drug.
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
Caution is especially urged when using new or infrequently ordered drugs.
bf bf bf bf bf bf bf bf bf bf bf
Library of Congress Cataloging-in-Publication Data
bf bf bf bf
Names: Sullivan, Debra D., author. bf bf bf bf
Title: Guide to clinical documentation/Debra D. Sullivan.
bf b f b f b f b f bf
Description: Łird edition. | Philadelphia: F.A. Davis Company, [2019] bf bf bf bf bf bf bf bf
| Includes bibliographical references and index.
bf bf bf bf bf bf
Identifiers: LCCN 2018019472 (print) | LCCN 2018019898 (ebook) | bf bf bf b f bf bf bf bf
ISBN9780803669994 | ISBN 9780803666627 (pbk.)
bf bf bf bf bf bf
Subjects: | MESH: Forms and Records Control--methods | bf bf bf bf bf bf bf
MedicalRecords--standards
bf bf
Classification: LCC R697.P45 (ebook) | LCC R697.P45 (print) | NLM W 80 | bf bf bf bf bf bf bf bf bf bf bf bf
DDC651.5/04261--dc23
bf bf
LC record available at https://lccn.loc.gov/2018019472
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Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A.
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
granted a photocopy license by CCC, a separate system of payment has been arranged. Łe fee code for users of the Transactional
bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf bf
Reporting Service is:
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978-0-8036-6662-7/18 0 + $.25. bf bf bf
, Dedication
When I think back to 2004, when the first edition of this book
bf bf bf bf bf bf bf bf bf bf bf bf
bf was published, I think of a wonderful group of friends who
bf bf bf bf bf bf bf bf bf bf
bf were there to celebrate with me. As I anticipate the
bf bf bf bf bf bf bf bf bf
publicationof the third edition, almost all of those same
bf bf bf bf bf bf bf bf bf bf
bf wonderful friendsare still here, encouraging and supportingbf bf bf bf bf bf bf
bf me, and cheering meon to the finish line. Sadly, my dear
bf bf bf bf bf bf bf bf bf bf bf
bf friend Candy left us muchtoo soon, and I miss her sweet
bf bf bf bf bf bf bf bf bf bf bf
bf presence more than words can say.7e essence of her heart and
bf bf bf bf bf bf bf bf bf bf bf
bf soul is with me always. For the remaining STUB-C friends
bf bf bf bf bf bf bf bf bf
bf (Kent, Donna, Paige, Jeff, John, Brianna, Justin, Tim,
bf bf bf bf bf bf bf
bf Carla, and Jeff ), thanks for your friendship, your love, and
bf bf bf bf bf bf bf bf bf bf
bf your constancy in my life through the past two decades. I
bf bf bf bf bf bf bf bf bf bf
bf couldn’t ask for a better group of people to share life with! I
bf bf bf bf bf bf bf bf bf bf bf bf
bf hope there are many more decades to come!
bf bf bf bf bf bf bf
Not only have I been blessed with these incredible friends,
bf bf bf bf bf bf bf bf bf
bf butI am fortunate to have the most loving, caring, and
bf bf bf bf bf bf bf bf bf bf
bf supportivehusband any woman could hope for. Greg is an bf bf bf bf bf bf bf bf bf
bf unwavering source of encouragement and inspires and bf bf bf bf bf bf
bf challenges me to be the best I can be. He has stood beside bf bf bf bf bf bf bf bf bf bf bf bf
bf me without complaint through the days of writer’s block,
bf bf bf bf bf bf bf bf
looming deadlines, malfunctioning computers, and the often-
bf bf bf bf bf bf bf
self-imposed frenzy of my world. He has the insight to know bf bf bf bf bf bf bf bf bf bf
bf when to cheer me on, when to make me take a break, and
bf bf bf bf bf bf bf bf bf bf bf bf
bf when to give me space. I am so grateful for his calming
bf bf bf bf bf bf bf bf bf bf bf
bf influence, his ability to make bf bf bf bf
me laugh and not take myself too seriously, and all he
bf bf bf bf bf bf bf bf bf bf
bf does to keep things running smoothly in the Sullivan
bf bf bf bf bf bf bf bf
Copyright © 2019 by F. A. Davis Company. All rights
bf bf bf bf bf bf bf bf bf iii
reserved.
bf
