,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.y3A.y3Davisy3Compa
nyy31915y3Archy3Stree
t
Philadelphia,y3PAy3191
03y3www.fadavis.com
Copyrighty3 ©y3 2019y3 byy3 F.y3A.y3Davisy3 Company
Copyrighty3©y32019y3byy3F.y3A.y3Davisy3Company.y3Ally3rightsy3reserved.y3Łisy3producty3isy3protectedy3byy3copyright.y3Noy3pa
rty3ofy3ity3mayy3bey3reproduced,y3storedy3iny3ay3retrievaly3system,y3ory3transmittedy3iny3anyy3formy3ory3byy3anyy3means,y3electr
onic,y3mechanical,y3photocopying,y3recording,y3ory3otherwise,y3withouty3writteny3permissiony3fromy3they3publisher.
Printedy3iny3they3Unitedy3Statesy3ofy3America
Lasty3digity3indicatesy3printy3number:y310y39y38y37y36y35y34y33y32y31
Seniory3Acquisitionsy3Editor:y3Melissay3A.y3Duffield
y3Directory3ofy3Contenty3Development:y3Georgey3W.y3
Langy3Developmentaly3Editor:y3Stephaniey3Kelly
Arty3andy3Designy3Manager:y3Carolyny3 O’Brien
Contenty3Projecty3Manager:y3Megany3Suermann
Asy3newy3scientificy3informationy3becomesy3availabley3throughy3basicy3andy3clinicaly3research,y3recommendedy3treatmentsy3andy3dr
ugy3therapiesy3undergoy3changes.y3Łey3author(s)y3andy3publishery3havey3doney3everythingy3possibley3toy3makey3thisy3booky3accur
ate,y3upy3toy3date,y3andy3iny3accordy3withy3acceptedy3standardsy3aty3they3timey3ofy3publication.y3Łey3author(s),y3editors,y3andy3pu
blishery3arey3noty3responsibley3fory3errorsy3ory3omissionsy3ory3fory3consequencesy3fromy3applicationy3ofy3they3book,y3andy3makey3
noy3warranty,y3expressedy3ory3implied,y3iny3regardy3toy3they3contentsy3ofy3they3book.y3Anyy3practicey3describedy3iny3thisy3booky3
shouldy3bey3appliedy3byy3they3readery3iny3accordancey3withy3professionaly3standardsy3ofy3carey3usedy3iny3regardy3toy3they3uniquey
3circumstancesy3thaty3mayy3applyy3iny3eachy3situation.y3Łey3readery3isy3advisedy3alwaysy3toy3checky3producty3informationy3(packa
gey3inserts)y3fory3changesy3andy3newy3informationy3regardingy3dosey3andy3contraindicationsy3beforey3administeringy3anyy3drug.y3C
autiony3isy3especiallyy3urgedy3wheny3usingy3newy3ory3infrequentlyy3orderedy3drugs.
Libraryy3 ofy3 Congressy3 Cataloging-in-Publicationy3 Data
Names:y3 Sullivan,y3Debray3 D.,y3author.
Title:y3 Guidey 3 toy 3 clinicaly 3 documentation/Debray 3 D.y3Sullivan.
Description:y3Łirdy3edition.y3|y3Philadelphia:y3F.A.y3Davisy3Company,y3
[2019]y3|y3Includesy3bibliographicaly3referencesy3andy3index.
Identifiers:y3LCCNy32018019472y3(print)y3|y3LCCNy32018019898y3(ebook)y3|y3ISBN
y39780803669994y3|y3ISBNy39780803666627y3(pbk.)
Subjects:y3|y3MESH:y3Formsy3andy3Recordsy3Control--
methodsy3|y3Medicaly3Records--standards
Classification:y3LCCy3R697.P45y3(ebook)y3|y3LCCy3R697.P45y3(print)y3|y3NLM
y3Wy380y3|y3DDCy3651.5/04261--dc23
LCy3 recordy3 availabley3 aty3 https://lccn.loc.gov/2018019472
Authorizationy3toy3photocopyy3itemsy3fory3internaly3ory3personaly3use,y3ory3they3internaly3ory3personaly3usey3ofy3specificy3clients,y
3isy3grantedy3byy3F.y3A.y3Davisy3Companyy3fory3usersy3registeredy3withy3they3Copyrighty3Clearancey3Centery3(CCC)y3Transaction
aly3Reportingy3Service,y3providedy3thaty3they3feey3ofy3$.25y3pery3copyy3isy3paidy3directlyy3toy3CCC,y3222y3Rosewoody3Drive,y3D
anvers,y3MAy301923.y3Fory3thosey3organizationsy3thaty3havey3beeny3grantedy3ay3photocopyy3licensey3byy3CCC,y3ay3separatey3syste
my3ofy3paymenty3hasy3beeny3arranged.y3Łey3feey3codey3fory3usersy3ofy3they3Transactionaly3Reportingy3Servicey3is:
978-0-8036-6662-7/18y30y3+y3$.25.
, Dedication
Wheny3Iy3thinky3backy3toy32004,y3wheny3they3firsty3editiony3ofy3
thisy3booky3wasy3published,y3Iy3thinky3ofy3ay3wonderfuly3grou
py3ofy3friendsy3whoy3werey3therey3toy3celebratey3withy3me.y3Asy3
Iy3anticipatey3they3publicationy3ofy3they3thirdy3edition,y3almosty3
ally3ofy3thosey3samey3wonderfuly3friendsy3arey3stilly3here,y3enco
uragingy3andy3supportingy3me,y3andy3cheeringy3mey3ony3toy3they3f
inishy3line.y3Sadly,y3myy3deary3friendy3Candyy3lefty3usy3muchy3t
ooy3soon,y3andy3Iy3missy3hery3sweety3presencey3morey3thany3wo
rdsy3cany3say.y37ey3essencey3ofy3hery3hearty3andy3souly3isy3withy
3mey3always.y3Fory3they3remainingy3STUB-
Cy3friendsy3(Kent,y3Donna,y3Paige,y3Jeff,y3John,y3Brianna,y3J
ustin,y3Tim,y3Carla,y3andy3Jeffy3),y3thanksy3fory3youry3friends
hip,y3youry3love,y3andy3youry3constancyy3iny3myy3lifey3through
y3they3pasty3twoy3decades.y3Iy3couldn’ty3asky3fory3ay3bettery3group
y3ofy3peopley3toy3sharey3lifey3with!y3Iy3hopey3therey3arey3manyy3mo
rey3decadesy3toy3come!
Noty3onlyy3havey3Iy3beeny3blessedy3withy3thesey3incredibley3frie
nds,y3buty3Iy3amy3fortunatey3toy3havey3they3mosty3loving,y3carin
g,y3andy3supportivey3husbandy3anyy3womany3couldy3hopey3for.
y3Gregy3isy3any3unwaveringy3sourcey3ofy3encouragementy3andy
3inspiresy3andy3challengesy3mey3toy3bey3they3besty3Iy3cany3be.y3
Hey3hasy3stoody3besidey3mey3withouty3complainty3throughy3they
3daysy3ofy3writer’sy3block,y3loomingy3deadlines,y3malfunctioni
ngy3computers,y3andy3they3often-self-
imposedy3frenzyy3ofy3myy3world.y3Hey3hasy3they3insighty3toy3kn
owy3wheny3toy3cheery3mey3on,y3wheny3toy3makey3mey3takey3ay3b
reak,y3andy3wheny3toy3givey3mey3space.y3Iy3amy3soy3gratefuly3f
ory3hisy3calmingy3influence,y3hisy3abilityy3toy3makey3mey3laugh
Copyrighty3 ©y3 2019y3 byy3 F.y3A.y3Davisy3 Company.y3Ally3 r iii
ightsy3 reserved.
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.y3A.y3Davisy3Compa
nyy31915y3Archy3Stree
t
Philadelphia,y3PAy3191
03y3www.fadavis.com
Copyrighty3 ©y3 2019y3 byy3 F.y3A.y3Davisy3 Company
Copyrighty3©y32019y3byy3F.y3A.y3Davisy3Company.y3Ally3rightsy3reserved.y3Łisy3producty3isy3protectedy3byy3copyright.y3Noy3pa
rty3ofy3ity3mayy3bey3reproduced,y3storedy3iny3ay3retrievaly3system,y3ory3transmittedy3iny3anyy3formy3ory3byy3anyy3means,y3electr
onic,y3mechanical,y3photocopying,y3recording,y3ory3otherwise,y3withouty3writteny3permissiony3fromy3they3publisher.
Printedy3iny3they3Unitedy3Statesy3ofy3America
Lasty3digity3indicatesy3printy3number:y310y39y38y37y36y35y34y33y32y31
Seniory3Acquisitionsy3Editor:y3Melissay3A.y3Duffield
y3Directory3ofy3Contenty3Development:y3Georgey3W.y3
Langy3Developmentaly3Editor:y3Stephaniey3Kelly
Arty3andy3Designy3Manager:y3Carolyny3 O’Brien
Contenty3Projecty3Manager:y3Megany3Suermann
Asy3newy3scientificy3informationy3becomesy3availabley3throughy3basicy3andy3clinicaly3research,y3recommendedy3treatmentsy3andy3dr
ugy3therapiesy3undergoy3changes.y3Łey3author(s)y3andy3publishery3havey3doney3everythingy3possibley3toy3makey3thisy3booky3accur
ate,y3upy3toy3date,y3andy3iny3accordy3withy3acceptedy3standardsy3aty3they3timey3ofy3publication.y3Łey3author(s),y3editors,y3andy3pu
blishery3arey3noty3responsibley3fory3errorsy3ory3omissionsy3ory3fory3consequencesy3fromy3applicationy3ofy3they3book,y3andy3makey3
noy3warranty,y3expressedy3ory3implied,y3iny3regardy3toy3they3contentsy3ofy3they3book.y3Anyy3practicey3describedy3iny3thisy3booky3
shouldy3bey3appliedy3byy3they3readery3iny3accordancey3withy3professionaly3standardsy3ofy3carey3usedy3iny3regardy3toy3they3uniquey
3circumstancesy3thaty3mayy3applyy3iny3eachy3situation.y3Łey3readery3isy3advisedy3alwaysy3toy3checky3producty3informationy3(packa
gey3inserts)y3fory3changesy3andy3newy3informationy3regardingy3dosey3andy3contraindicationsy3beforey3administeringy3anyy3drug.y3C
autiony3isy3especiallyy3urgedy3wheny3usingy3newy3ory3infrequentlyy3orderedy3drugs.
Libraryy3 ofy3 Congressy3 Cataloging-in-Publicationy3 Data
Names:y3 Sullivan,y3Debray3 D.,y3author.
Title:y3 Guidey 3 toy 3 clinicaly 3 documentation/Debray 3 D.y3Sullivan.
Description:y3Łirdy3edition.y3|y3Philadelphia:y3F.A.y3Davisy3Company,y3
[2019]y3|y3Includesy3bibliographicaly3referencesy3andy3index.
Identifiers:y3LCCNy32018019472y3(print)y3|y3LCCNy32018019898y3(ebook)y3|y3ISBN
y39780803669994y3|y3ISBNy39780803666627y3(pbk.)
Subjects:y3|y3MESH:y3Formsy3andy3Recordsy3Control--
methodsy3|y3Medicaly3Records--standards
Classification:y3LCCy3R697.P45y3(ebook)y3|y3LCCy3R697.P45y3(print)y3|y3NLM
y3Wy380y3|y3DDCy3651.5/04261--dc23
LCy3 recordy3 availabley3 aty3 https://lccn.loc.gov/2018019472
Authorizationy3toy3photocopyy3itemsy3fory3internaly3ory3personaly3use,y3ory3they3internaly3ory3personaly3usey3ofy3specificy3clients,y
3isy3grantedy3byy3F.y3A.y3Davisy3Companyy3fory3usersy3registeredy3withy3they3Copyrighty3Clearancey3Centery3(CCC)y3Transaction
aly3Reportingy3Service,y3providedy3thaty3they3feey3ofy3$.25y3pery3copyy3isy3paidy3directlyy3toy3CCC,y3222y3Rosewoody3Drive,y3D
anvers,y3MAy301923.y3Fory3thosey3organizationsy3thaty3havey3beeny3grantedy3ay3photocopyy3licensey3byy3CCC,y3ay3separatey3syste
my3ofy3paymenty3hasy3beeny3arranged.y3Łey3feey3codey3fory3usersy3ofy3they3Transactionaly3Reportingy3Servicey3is:
978-0-8036-6662-7/18y30y3+y3$.25.
, Dedication
Wheny3Iy3thinky3backy3toy32004,y3wheny3they3firsty3editiony3ofy3
thisy3booky3wasy3published,y3Iy3thinky3ofy3ay3wonderfuly3grou
py3ofy3friendsy3whoy3werey3therey3toy3celebratey3withy3me.y3Asy3
Iy3anticipatey3they3publicationy3ofy3they3thirdy3edition,y3almosty3
ally3ofy3thosey3samey3wonderfuly3friendsy3arey3stilly3here,y3enco
uragingy3andy3supportingy3me,y3andy3cheeringy3mey3ony3toy3they3f
inishy3line.y3Sadly,y3myy3deary3friendy3Candyy3lefty3usy3muchy3t
ooy3soon,y3andy3Iy3missy3hery3sweety3presencey3morey3thany3wo
rdsy3cany3say.y37ey3essencey3ofy3hery3hearty3andy3souly3isy3withy
3mey3always.y3Fory3they3remainingy3STUB-
Cy3friendsy3(Kent,y3Donna,y3Paige,y3Jeff,y3John,y3Brianna,y3J
ustin,y3Tim,y3Carla,y3andy3Jeffy3),y3thanksy3fory3youry3friends
hip,y3youry3love,y3andy3youry3constancyy3iny3myy3lifey3through
y3they3pasty3twoy3decades.y3Iy3couldn’ty3asky3fory3ay3bettery3group
y3ofy3peopley3toy3sharey3lifey3with!y3Iy3hopey3therey3arey3manyy3mo
rey3decadesy3toy3come!
Noty3onlyy3havey3Iy3beeny3blessedy3withy3thesey3incredibley3frie
nds,y3buty3Iy3amy3fortunatey3toy3havey3they3mosty3loving,y3carin
g,y3andy3supportivey3husbandy3anyy3womany3couldy3hopey3for.
y3Gregy3isy3any3unwaveringy3sourcey3ofy3encouragementy3andy
3inspiresy3andy3challengesy3mey3toy3bey3they3besty3Iy3cany3be.y3
Hey3hasy3stoody3besidey3mey3withouty3complainty3throughy3they
3daysy3ofy3writer’sy3block,y3loomingy3deadlines,y3malfunctioni
ngy3computers,y3andy3they3often-self-
imposedy3frenzyy3ofy3myy3world.y3Hey3hasy3they3insighty3toy3kn
owy3wheny3toy3cheery3mey3on,y3wheny3toy3makey3mey3takey3ay3b
reak,y3andy3wheny3toy3givey3mey3space.y3Iy3amy3soy3gratefuly3f
ory3hisy3calmingy3influence,y3hisy3abilityy3toy3makey3mey3laugh
Copyrighty3 ©y3 2019y3 byy3 F.y3A.y3Davisy3 Company.y3Ally3 r iii
ightsy3 reserved.
