,GUIDE TO
CIinicaI
Documentation
THIRD EDITION
Debra D. SuIIivan, PhD, RN, PA-C
Iead Advanced Practice Provider
Academic UroIogy and UrogynecoIogy of Arizona
IitchfieId Park, AZ
Owner, SuIIivan ConsuIting Services
MedicoIegaI ConsuIting
GIendaIe, AZ
,F. A. Davis Company
1915 Arch Street
PhiIadeIphia, PA 19103
www.fadavis.com
Copyright © 2019 by F. A. Davis Company
Copyright © 2019 by F. A. Davis Company. AII rights reserved. This product is protected by copyright. No part of it may be reproduced,
stored in a retrievaI system, or transmitted in any form or by any means, eIectronic, mechanicaI, photocopying, recording, or otherwise,
without written permission from the pubIisher.
Printed in the United States of America
Iast digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Senior Acquisitions Editor: MeIissa A. DuffieId
Director of Content DeveIopment: George W. Iang
DeveIopmentaI Editor: Stephanie KeIIy
Art and Design Manager: CaroIyn O’Brien
Content Project Manager: Megan Suermann
As new scientific information becomes avaiIabIe through basic and cIinicaI research, recommended treatments and drug therapies undergo
changes. The author(s) and pubIisher have done everything possibIe to make this book accurate, up to date, and in accord with accepted
standards at the time of pubIication. The author(s), editors, and pubIisher are not responsibIe for errors or omissions or for consequences
from appIication of the book, and make no warranty, expressed or impIied, in regard to the contents of the book. Any practice described in
this book shouId be appIied by the reader in accordance with professionaI standards of care used in regard to the unique circumstances that
may appIy in each situation. The reader is advised aIways to check product information (package inserts) for changes and new information
regarding dose and contraindications before administering any drug. Caution is especiaIIy urged when using new or infrequentIy ordered
drugs.
Iibrary of Congress CataIoging-in-PubIication Data
Names: SuIIivan, Debra D., author.
TitIe: Guide to cIinicaI documentation/Debra D. SuIIivan.
Description: Third edition. | PhiIadeIphia: F.A. Davis Company, [2019] |
IncIudes bibIiographicaI references and index.
Identifiers: ICCN 2018019472 (print) | ICCN 2018019898 (ebook) | ISBN 9780803669994
| ISBN 9780803666627 (pbk.)
Subjects: | MESH: Forms and Records ControI--methods | MedicaI
Records--standards
CIassification: ICC R697.P45 (ebook) | ICC R697.P45 (print) | NIM W 80 | DDC
651.5/04261--dc23
IC record avaiIabIe at https://Iccn.Ioc.gov/2018019472
Authorization to photocopy items for internaI or personaI use, or the internaI or personaI use of specific cIients, is granted by F. A.
Davis Company for users registered with the Copyright CIearance Center (CCC) TransactionaI Reporting Service, provided that the fee
of $.25 per copy is paid directIy to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a
photocopy Iicense by CCC, a separate system of payment has been arranged. The fee code for users of the TransactionaI Reporting
Service is:
978-0-8036-6662-7/18 0 + $.25.
, Dedication
When I think back to 2004, when the first edition of this book
was pubIished, I think of a wonderfuI group of friends who
were there to ceIebrate with me. As I anticipate the pubIication
of the third edition, aImost aII of those same wonderfuI friends
are stiII here, encouraging and supporting me, and cheering me
on to the finish Iine. SadIy, my dear friend Candy Ieft us much
too soon, and I miss her sweet presence more than words can
say. 7e essence of her heart and souI is with me aIways. For
the remaining STUB-C friends (Kent, Donna, Paige, Jeff,
John, Brianna, Justin, Tim, CarIa, and Jeff ), thanks for your
friendship, your Iove, and your constancy in my Iife through
the past two decades. I couIdn’t ask for a better group of peopIe
to share Iife with! I hope there are many more decades to come!
Not onIy have I been bIessed with these incredibIe friends,
but I am fortunate to have the most Ioving, caring, and
supportive husband any woman couId hope for. Greg is an
unwavering source of encouragement and inspires and
chaIIenges me to be the best I can be. He has stood beside me
without compIaint through the days of writer’s bIock,
Iooming deadIines, maIfunctioning computers, and the
often-seIf-imposed frenzy of my worId. 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 gratefuI for his caIming
infIuence, his abiIity to make
me Iaugh and not take myseIf too seriousIy, and aII he does
to keep things running smoothIy in the SuIIivan househoId.
7anks, Greg, for aII this, and so much more. And I promise...
no fourth edition!
iii
CIinicaI
Documentation
THIRD EDITION
Debra D. SuIIivan, PhD, RN, PA-C
Iead Advanced Practice Provider
Academic UroIogy and UrogynecoIogy of Arizona
IitchfieId Park, AZ
Owner, SuIIivan ConsuIting Services
MedicoIegaI ConsuIting
GIendaIe, AZ
,F. A. Davis Company
1915 Arch Street
PhiIadeIphia, PA 19103
www.fadavis.com
Copyright © 2019 by F. A. Davis Company
Copyright © 2019 by F. A. Davis Company. AII rights reserved. This product is protected by copyright. No part of it may be reproduced,
stored in a retrievaI system, or transmitted in any form or by any means, eIectronic, mechanicaI, photocopying, recording, or otherwise,
without written permission from the pubIisher.
Printed in the United States of America
Iast digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Senior Acquisitions Editor: MeIissa A. DuffieId
Director of Content DeveIopment: George W. Iang
DeveIopmentaI Editor: Stephanie KeIIy
Art and Design Manager: CaroIyn O’Brien
Content Project Manager: Megan Suermann
As new scientific information becomes avaiIabIe through basic and cIinicaI research, recommended treatments and drug therapies undergo
changes. The author(s) and pubIisher have done everything possibIe to make this book accurate, up to date, and in accord with accepted
standards at the time of pubIication. The author(s), editors, and pubIisher are not responsibIe for errors or omissions or for consequences
from appIication of the book, and make no warranty, expressed or impIied, in regard to the contents of the book. Any practice described in
this book shouId be appIied by the reader in accordance with professionaI standards of care used in regard to the unique circumstances that
may appIy in each situation. The reader is advised aIways to check product information (package inserts) for changes and new information
regarding dose and contraindications before administering any drug. Caution is especiaIIy urged when using new or infrequentIy ordered
drugs.
Iibrary of Congress CataIoging-in-PubIication Data
Names: SuIIivan, Debra D., author.
TitIe: Guide to cIinicaI documentation/Debra D. SuIIivan.
Description: Third edition. | PhiIadeIphia: F.A. Davis Company, [2019] |
IncIudes bibIiographicaI references and index.
Identifiers: ICCN 2018019472 (print) | ICCN 2018019898 (ebook) | ISBN 9780803669994
| ISBN 9780803666627 (pbk.)
Subjects: | MESH: Forms and Records ControI--methods | MedicaI
Records--standards
CIassification: ICC R697.P45 (ebook) | ICC R697.P45 (print) | NIM W 80 | DDC
651.5/04261--dc23
IC record avaiIabIe at https://Iccn.Ioc.gov/2018019472
Authorization to photocopy items for internaI or personaI use, or the internaI or personaI use of specific cIients, is granted by F. A.
Davis Company for users registered with the Copyright CIearance Center (CCC) TransactionaI Reporting Service, provided that the fee
of $.25 per copy is paid directIy to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a
photocopy Iicense by CCC, a separate system of payment has been arranged. The fee code for users of the TransactionaI Reporting
Service is:
978-0-8036-6662-7/18 0 + $.25.
, Dedication
When I think back to 2004, when the first edition of this book
was pubIished, I think of a wonderfuI group of friends who
were there to ceIebrate with me. As I anticipate the pubIication
of the third edition, aImost aII of those same wonderfuI friends
are stiII here, encouraging and supporting me, and cheering me
on to the finish Iine. SadIy, my dear friend Candy Ieft us much
too soon, and I miss her sweet presence more than words can
say. 7e essence of her heart and souI is with me aIways. For
the remaining STUB-C friends (Kent, Donna, Paige, Jeff,
John, Brianna, Justin, Tim, CarIa, and Jeff ), thanks for your
friendship, your Iove, and your constancy in my Iife through
the past two decades. I couIdn’t ask for a better group of peopIe
to share Iife with! I hope there are many more decades to come!
Not onIy have I been bIessed with these incredibIe friends,
but I am fortunate to have the most Ioving, caring, and
supportive husband any woman couId hope for. Greg is an
unwavering source of encouragement and inspires and
chaIIenges me to be the best I can be. He has stood beside me
without compIaint through the days of writer’s bIock,
Iooming deadIines, maIfunctioning computers, and the
often-seIf-imposed frenzy of my worId. 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 gratefuI for his caIming
infIuence, his abiIity to make
me Iaugh and not take myseIf too seriousIy, and aII he does
to keep things running smoothIy in the SuIIivan househoId.
7anks, Greg, for aII this, and so much more. And I promise...
no fourth edition!
iii
