,GUIDE TO
Clinical
4c
Documentation
THIRD EDITION
4c
4c
Debra4cD.4cSullivan,4cPhD,4cRN,4cPA-C
Lead4c Advanced 4c Practice 4c Provider
Academic 4cUrology 4cand4cUrogynecology 4cof4cArizona 4c Litch
field 4c Park, 4c AZ
Owner,4cSullivan 4c Consulting 4c Servic
es 4c Medicolegal 4c Consulting
Glendale,4 c AZ
,F.4cA.4cDavis4cCompa
ny4c19154cArch4cStre
et
Philadelphia,4cPA4c191034cwww.fadavis.
com
Copyright4c©4c20194cby4cF.4cA.4cDavis4cCompany
Copyright4c©4c20194cby4cF.4cA.4cDavis4cCompany.4cAll4crights4creserved.4cThis4cproduct4cis4cprotected4cby4ccopyright.4cNo4cpart4cof4cit4c
may4cbe4creproduced,4cstored4cin4ca4cretrieval4csystem,4cor4ctransmitted4cin4cany4cform4cor4cby4cany4cmeans,4celectronic,4cmechanical,4cph
otocopying,4crecording,4cor4cotherwise,4cwithout4cwritten4cpermission4cfrom4cthe4cpublisher.
Printed4c in4c the4c United4c States4cof4c America
Last4cdigit4cindicates4cprint4cnumber:4c104c94c84c74c64c54c44c34c24c1
Senior4cAcquisitions4cEditor:4cMelissa4cA.4cDuffield4c
Director4cof4cContent4cDevelopment:4cGeorge4cW.4cLang
4cDevelopmental4cEditor:4cStephanie4cKelly
Art4cand4cDesign4cManager:4cCarolyn4cO’Brien
Content4cProject4cManager:4cMegan4cSuermann
As4cnew4cscientific4cinformation4cbecomes4cavailable4cthrough4cbasic4cand4cclinical4cresearch,4crecommended4ctreatments4cand4cdrug4ctherap
ies4cundergo4cchanges.4cThe4cauthor(s)4cand4cpublisher4chave4cdone4ceverything4cpossible4cto4cmake4cthis4cbook4caccurate,4cup4cto4cdate,4
cand4cin4caccord4cwith4caccepted4cstandards4cat4cthe4ctime4cof4cpublication.4cThe4cauthor(s),4ceditors,4cand4cpublisher4care4cnot4cresponsibl
e4cfor4cerrors4cor4comissions4cor4cfor4cconsequences4cfrom4capplication4cof4cthe4cbook,4cand4cmake4cno4cwarranty,4cexpressed4cor4cimplied,4
cin4cregard4cto4cthe4ccontents4cof4cthe4cbook.4cAny4cpractice4cdescribed4cin4cthis4cbook4cshould4cbe4capplied4cby4cthe4creader4cin4caccordance4
cwith4cprofessional4cstandards4cof4ccare4cused4cin4cregard4cto4cthe4cunique4ccircumstances4cthat4cmay4capply4cin4ceach4csituation.4cThe4creader
4cis4cadvised4calways4cto4ccheck4cproduct4cinformation4c(package4cinserts)4cfor4cchanges4cand4cnew4cinformation4cregarding4cdose4cand4ccon
traindications4cbefore4cadministering4cany4cdrug.4cCaution4cis4cespecially4curged4cwhen4cusing4cnew4cor4cinfrequently4cordered4cdrugs.
Library4c of4c Congress4c Cataloging-in-Publication4c Data
Names:4cSullivan,4cDebra4cD.,4cauthor.
Title:4cGuide4c to4c clinical4c documentation/Debra4c D.4cSullivan.
Description:4cThird4cedition.4c|4cPhiladelphia:4cF.A.4cDavis4cCompany,4c[20
19]4c|4cIncludes4cbibliographical4creferences4cand4cindex.
Identifiers:4cLCCN4c20180194724c(print)4c|4cLCCN4c20180198984c(ebook)4c|4cISBN4c9780
8036699944c|4cISBN4c97808036666274c(pbk.)
Subjects:4c|4cMESH:4cForms4cand4cRecords4cControl--
methods4c|4cMedical4cRecords--standards
Classification:4cLCC4cR697.P454c(ebook)4c|4cLCC4cR697.P454c(print)4c|4cNLM4cW4c80
4c|4cDDC4 c 651.5/04261--dc23
LC4crecord4cavailable4cat4chttps://lccn.loc.gov/2018019472
Authorization4cto4cphotocopy4citems4cfor4cinternal4cor4cpersonal4cuse,4cor4cthe4cinternal4cor4cpersonal4cuse4cof4cspecific4cclients,4cis4cgrant
ed4cby4cF.4cA.4cDavis4cCompany4cfor4cusers4cregistered4cwith4cthe4cCopyright4cClearance4cCenter4c(CCC)4cTransactional4cReporting4cSer
vice,4cprovided4cthat4cthe4cfee4cof4c$.254cper4ccopy4cis4cpaid4cdirectly4cto4cCCC,4c2224cRosewood4cDrive,4cDanvers,4cMA4c01923.4cFor4ctho
se4corganizations4cthat4chave4cbeen4cgranted4ca4cphotocopy4clicense4cby4cCCC,4ca4cseparate4csystem4cof4cpayment4chas4cbeen4carranged.4c
The4cfee4ccode4cfor4cusers4cof4cthe4cTransactional4cReporting4cService4cis:
978-0-8036-6662-7/184c04c+4c$.25.
, Dedication
When4cI4cthink4cback4cto4c2004,4cwhen4cthe4cfirst4cedition4cof4cthis4
cbook4cwas4cpublished,4cI4cthink4cof4ca4cwonderful4cgroup4cof4cfri
ends4cwho4cwere4cthere4cto4ccelebrate4cwith4cme.4cAs4cI4canticipate4
cthe4cpublication4cof4cthe4cthird4cedition,4calmost4call4cof4cthose4csa
me4cwonderful4cfriends4care4cstill4chere,4cencouraging4cand4csuppo
rting4cme,4cand4ccheering4cme4con4cto4cthe4cfinish4cline.4cSadly,4cmy4
cdear4cfriend4cCandy4cleft4cus4cmuch4ctoo4csoon,4cand4cI4cmiss4cher
4csweet4cpresence4cmore4cthan4cwords4ccan4csay.4c7e4cessence4cof4c
her4cheart4cand4csoul4cis4cwith4cme4calways.4cFor4cthe4cremainin
g4cSTUB-
C4cfriends4c(Kent,4cDonna,4cPaige,4cJeff,4cJohn,4cBrianna,4cJus
tin,4cTim,4cCarla,4cand4cJeff4c),4cthanks4cfor4cyour4cfriendship,4cyo
ur4clove,4cand4cyour4cconstancy4cin4cmy4clife4cthrough4cthe4cpast4ct
wo4cdecades.4cI4ccouldn’t4cask4cfor4ca4cbetter4cgroup4cof4cpeople4cto4c
share4clife4cwith!4cI4chope4cthere4care4cmany4cmore4cdecades4cto4cco
me!
Not4conly4chave4cI4cbeen4cblessed4cwith4cthese4cincredible4cfriends
,4cbut4cI4cam4cfortunate4cto4chave4cthe4cmost4cloving,4ccaring,4cand4c
supportive4chusband4cany4cwoman4ccould4chope4cfor.4cGreg4cis4c
an4cunwavering4csource4cof4cencouragement4cand4cinspires4cand4c
challenges4cme4cto4cbe4cthe4cbest4cI4ccan4cbe.4cHe4chas4cstood4cbesi
de4cme4cwithout4ccomplaint4cthrough4cthe4cdays4cof4cwriter’s4cblo
ck,4clooming4cdeadlines,4cmalfunctioning4ccomputers,4cand4cthe4
coften-self-
imposed4cfrenzy4cof4cmy4cworld.4cHe4chas4cthe4cinsight4cto4cknow4c
when4cto4ccheer4cme4con,4cwhen4cto4cmake4cme4ctake4ca4cbreak,4ca
nd4cwhen4cto4cgive4cme4cspace.4cI4cam4cso4cgrateful4cfor4chis4ccalm
ing4cinfluence,4chis4cability4cto4cmake
Copyright4c©4c20194cby4cF.4cA.4cDavis4cCompany.4cAll4crights4c iii
reserved.
Clinical
4c
Documentation
THIRD EDITION
4c
4c
Debra4cD.4cSullivan,4cPhD,4cRN,4cPA-C
Lead4c Advanced 4c Practice 4c Provider
Academic 4cUrology 4cand4cUrogynecology 4cof4cArizona 4c Litch
field 4c Park, 4c AZ
Owner,4cSullivan 4c Consulting 4c Servic
es 4c Medicolegal 4c Consulting
Glendale,4 c AZ
,F.4cA.4cDavis4cCompa
ny4c19154cArch4cStre
et
Philadelphia,4cPA4c191034cwww.fadavis.
com
Copyright4c©4c20194cby4cF.4cA.4cDavis4cCompany
Copyright4c©4c20194cby4cF.4cA.4cDavis4cCompany.4cAll4crights4creserved.4cThis4cproduct4cis4cprotected4cby4ccopyright.4cNo4cpart4cof4cit4c
may4cbe4creproduced,4cstored4cin4ca4cretrieval4csystem,4cor4ctransmitted4cin4cany4cform4cor4cby4cany4cmeans,4celectronic,4cmechanical,4cph
otocopying,4crecording,4cor4cotherwise,4cwithout4cwritten4cpermission4cfrom4cthe4cpublisher.
Printed4c in4c the4c United4c States4cof4c America
Last4cdigit4cindicates4cprint4cnumber:4c104c94c84c74c64c54c44c34c24c1
Senior4cAcquisitions4cEditor:4cMelissa4cA.4cDuffield4c
Director4cof4cContent4cDevelopment:4cGeorge4cW.4cLang
4cDevelopmental4cEditor:4cStephanie4cKelly
Art4cand4cDesign4cManager:4cCarolyn4cO’Brien
Content4cProject4cManager:4cMegan4cSuermann
As4cnew4cscientific4cinformation4cbecomes4cavailable4cthrough4cbasic4cand4cclinical4cresearch,4crecommended4ctreatments4cand4cdrug4ctherap
ies4cundergo4cchanges.4cThe4cauthor(s)4cand4cpublisher4chave4cdone4ceverything4cpossible4cto4cmake4cthis4cbook4caccurate,4cup4cto4cdate,4
cand4cin4caccord4cwith4caccepted4cstandards4cat4cthe4ctime4cof4cpublication.4cThe4cauthor(s),4ceditors,4cand4cpublisher4care4cnot4cresponsibl
e4cfor4cerrors4cor4comissions4cor4cfor4cconsequences4cfrom4capplication4cof4cthe4cbook,4cand4cmake4cno4cwarranty,4cexpressed4cor4cimplied,4
cin4cregard4cto4cthe4ccontents4cof4cthe4cbook.4cAny4cpractice4cdescribed4cin4cthis4cbook4cshould4cbe4capplied4cby4cthe4creader4cin4caccordance4
cwith4cprofessional4cstandards4cof4ccare4cused4cin4cregard4cto4cthe4cunique4ccircumstances4cthat4cmay4capply4cin4ceach4csituation.4cThe4creader
4cis4cadvised4calways4cto4ccheck4cproduct4cinformation4c(package4cinserts)4cfor4cchanges4cand4cnew4cinformation4cregarding4cdose4cand4ccon
traindications4cbefore4cadministering4cany4cdrug.4cCaution4cis4cespecially4curged4cwhen4cusing4cnew4cor4cinfrequently4cordered4cdrugs.
Library4c of4c Congress4c Cataloging-in-Publication4c Data
Names:4cSullivan,4cDebra4cD.,4cauthor.
Title:4cGuide4c to4c clinical4c documentation/Debra4c D.4cSullivan.
Description:4cThird4cedition.4c|4cPhiladelphia:4cF.A.4cDavis4cCompany,4c[20
19]4c|4cIncludes4cbibliographical4creferences4cand4cindex.
Identifiers:4cLCCN4c20180194724c(print)4c|4cLCCN4c20180198984c(ebook)4c|4cISBN4c9780
8036699944c|4cISBN4c97808036666274c(pbk.)
Subjects:4c|4cMESH:4cForms4cand4cRecords4cControl--
methods4c|4cMedical4cRecords--standards
Classification:4cLCC4cR697.P454c(ebook)4c|4cLCC4cR697.P454c(print)4c|4cNLM4cW4c80
4c|4cDDC4 c 651.5/04261--dc23
LC4crecord4cavailable4cat4chttps://lccn.loc.gov/2018019472
Authorization4cto4cphotocopy4citems4cfor4cinternal4cor4cpersonal4cuse,4cor4cthe4cinternal4cor4cpersonal4cuse4cof4cspecific4cclients,4cis4cgrant
ed4cby4cF.4cA.4cDavis4cCompany4cfor4cusers4cregistered4cwith4cthe4cCopyright4cClearance4cCenter4c(CCC)4cTransactional4cReporting4cSer
vice,4cprovided4cthat4cthe4cfee4cof4c$.254cper4ccopy4cis4cpaid4cdirectly4cto4cCCC,4c2224cRosewood4cDrive,4cDanvers,4cMA4c01923.4cFor4ctho
se4corganizations4cthat4chave4cbeen4cgranted4ca4cphotocopy4clicense4cby4cCCC,4ca4cseparate4csystem4cof4cpayment4chas4cbeen4carranged.4c
The4cfee4ccode4cfor4cusers4cof4cthe4cTransactional4cReporting4cService4cis:
978-0-8036-6662-7/184c04c+4c$.25.
, Dedication
When4cI4cthink4cback4cto4c2004,4cwhen4cthe4cfirst4cedition4cof4cthis4
cbook4cwas4cpublished,4cI4cthink4cof4ca4cwonderful4cgroup4cof4cfri
ends4cwho4cwere4cthere4cto4ccelebrate4cwith4cme.4cAs4cI4canticipate4
cthe4cpublication4cof4cthe4cthird4cedition,4calmost4call4cof4cthose4csa
me4cwonderful4cfriends4care4cstill4chere,4cencouraging4cand4csuppo
rting4cme,4cand4ccheering4cme4con4cto4cthe4cfinish4cline.4cSadly,4cmy4
cdear4cfriend4cCandy4cleft4cus4cmuch4ctoo4csoon,4cand4cI4cmiss4cher
4csweet4cpresence4cmore4cthan4cwords4ccan4csay.4c7e4cessence4cof4c
her4cheart4cand4csoul4cis4cwith4cme4calways.4cFor4cthe4cremainin
g4cSTUB-
C4cfriends4c(Kent,4cDonna,4cPaige,4cJeff,4cJohn,4cBrianna,4cJus
tin,4cTim,4cCarla,4cand4cJeff4c),4cthanks4cfor4cyour4cfriendship,4cyo
ur4clove,4cand4cyour4cconstancy4cin4cmy4clife4cthrough4cthe4cpast4ct
wo4cdecades.4cI4ccouldn’t4cask4cfor4ca4cbetter4cgroup4cof4cpeople4cto4c
share4clife4cwith!4cI4chope4cthere4care4cmany4cmore4cdecades4cto4cco
me!
Not4conly4chave4cI4cbeen4cblessed4cwith4cthese4cincredible4cfriends
,4cbut4cI4cam4cfortunate4cto4chave4cthe4cmost4cloving,4ccaring,4cand4c
supportive4chusband4cany4cwoman4ccould4chope4cfor.4cGreg4cis4c
an4cunwavering4csource4cof4cencouragement4cand4cinspires4cand4c
challenges4cme4cto4cbe4cthe4cbest4cI4ccan4cbe.4cHe4chas4cstood4cbesi
de4cme4cwithout4ccomplaint4cthrough4cthe4cdays4cof4cwriter’s4cblo
ck,4clooming4cdeadlines,4cmalfunctioning4ccomputers,4cand4cthe4
coften-self-
imposed4cfrenzy4cof4cmy4cworld.4cHe4chas4cthe4cinsight4cto4cknow4c
when4cto4ccheer4cme4con,4cwhen4cto4cmake4cme4ctake4ca4cbreak,4ca
nd4cwhen4cto4cgive4cme4cspace.4cI4cam4cso4cgrateful4cfor4chis4ccalm
ing4cinfluence,4chis4cability4cto4cmake
Copyright4c©4c20194cby4cF.4cA.4cDavis4cCompany.4cAll4crights4c iii
reserved.
