,Test Bank for Guide to Clinical Documentation 3rd
wi wi wi wi wi wi wi wi
Edition by Debra D Sullivan
wi wi wi wi
GUIDE TO
Clinical Document wi
ation
THIRD EDITION
DebrawiD.wiSullivan,wiPhD,wiRN,wiPA-C
Leadw i Advancedw i Practicew i Provider
AcademicwiUrology wi andwiUrogynecology wiofwiAriz
ona wi LitchfieldwiPark,wiAZ
Owner,wiSullivanw i Consultingwi Service
s wi MedicolegalwiConsulting
Glendale,w i AZ
,F.wiA.wiDaviswiCompa
nywi1915wiArchwiStree
t
Philadelphia,wiPAwi191
03wiwww.fadavis.com
Copyrightwi ©wi 2019wi bywi F.wiA.wiDaviswi Company
Copyrightwi©wi2019wibywiF.wiA.wiDaviswiCompany.wiAllwirightswireserved.wiŁiswiproductwiiswiprotectedwibywicopyright.wiNowipa
rtwiofwiitwimaywibewireproduced,wistoredwiinwiawiretrievalwisystem,wiorwitransmittedwiinwianywiformwiorwibywianywimeans,wielectr
onic,wimechanical,wiphotocopying,wirecording,wiorwiotherwise,wiwithoutwiwrittenwipermissionwifromwithewipublisher.
PrintedwiinwithewiUnitedwiStateswiofwiAmerica
Lastwidigitwiindicateswiprintwinumber:wi10wi9wi8wi7wi6wi5wi4wi3wi2wi1
SeniorwiAcquisitionswiEditor:wiMelissawiA.wiDuffield
wiDirectorwiofwiContentwiDevelopment:wiGeorgewiW.wi
LangwiDevelopmentalwiEditor:wiStephaniewiKelly
ArtwiandwiDesignwiManager:wiCarolynwi O’Brien
ContentwiProjectwiManager:wiMeganwiSuermann
Aswinewwiscientificwiinformationwibecomeswiavailablewithroughwibasicwiandwiclinicalwiresearch,wirecommendedwitreatmentswiandwidr
ugwitherapieswiundergowichanges.wiŁewiauthor(s)wiandwipublisherwihavewidonewieverythingwipossiblewitowimakewithiswibookwiaccur
ate,wiupwitowidate,wiandwiinwiaccordwiwithwiacceptedwistandardswiatwithewitimewiofwipublication.wiŁewiauthor(s),wieditors,wiandwipu
blisherwiarewinotwiresponsiblewiforwierrorswiorwiomissionswiorwiforwiconsequenceswifromwiapplicationwiofwithewibook,wiandwimakewi
nowiwarranty,wiexpressedwiorwiimplied,wiinwiregardwitowithewicontentswiofwithewibook.wiAnywipracticewidescribedwiinwithiswibookwi
shouldwibewiappliedwibywithewireaderwiinwiaccordancewiwithwiprofessionalwistandardswiofwicarewiusedwiinwiregardwitowithewiunique
wicircumstanceswithatwimaywiapplywiinwieachwisituation.wiŁewireaderwiiswiadvisedwialwayswitowicheckwiproductwiinformationwi(pack
agewiinserts)wiforwichangeswiandwinewwiinformationwiregardingwidosewiandwicontraindicationswibeforewiadministeringwianywidrug.wi
Cautionwiiswiespeciallywiurgedwiwhenwiusingwinewwiorwiinfrequentlywiorderedwidrugs.
Librarywi ofwi Congresswi Cataloging-in-Publicationwi Data
Names:wi Sullivan,wiDebrawi D.,wiauthor.
Title:wi Guidew i tow i clinicalw i documentation/Debraw i D.wiSullivan.
Description:wiŁirdwiedition.wi|wiPhiladelphia:wiF.A.wiDaviswiCompany,wi
[2019]wi|wiIncludeswibibliographicalwireferenceswiandwiindex.
Identifiers:wiLCCNwi2018019472wi(print)wi|wiLCCNwi2018019898 wi(ebook)wi|wiISBN
wi9780803669994wi|wiISBNwi9780803666627wi(pbk.)
Subjects:wi|wiMESH:wiFormswiandwiRecordswiControl--
methodswi|wiMedicalwiRecords--standards
Classification:wiLCCwiR697.P45wi(ebook)wi|wiLCCwiR697.P45wi(print)wi|wiNLM
wiWwi80wi|wiDDCwi651.5/04261--dc23
LCwi recordwi availablewi atwi https://lccn.loc.gov/2018019472
Authorizationwitowiphotocopywiitemswiforwiinternalwiorwipersonalwiuse,wiorwithewiinternalwiorwipersonalwiusewiofwispecificwiclients,w
iiswigrantedwibywiF.wiA.wiDaviswiCompanywiforwiuserswiregisteredwiwithwithewiCopyrightwiClearancewiCenterwi(CCC)wiTransactiona
lwiReportingwiService,wiprovidedwithatwithewifeewiofwi$.25wiperwicopywiiswipaidwidirectlywitowiCCC,wi222wiRosewoodwiDrive,wiDa
nvers,wiMAwi01923.wiForwithosewiorganizationswithatwihavewibeenwigrantedwiawiphotocopywilicensewibywiCCC,wiawiseparatewisyste
mwiofwipaymentwihaswibeenwiarranged.wiŁewifeewicodewiforwiuserswiofwithewiTransactionalwiReportingwiServicewiis:
978-0-8036-6662-7/18wi0wi+wi$.25.
, Dedication
WhenwiIwithinkwibackwitowi2004,wiwhenwithewifirstwieditionwiofwi
thiswibookwiwaswipublished,wiIwithinkwiofwiawiwonderfulwigrou
pwiofwifriendswiwhowiwerewitherewitowicelebratewiwithwime.wiAswi
Iwianticipatewithewipublicationwiofwithewithirdwiedition,wialmostwi
allwiofwithosewisamewiwonderfulwifriendswiarewistillwihere,wienco
uragingwiandwisupportingwime,wiandwicheeringwimewionwitowithewif
inishwiline.wiSadly,wimywidearwifriendwiCandywileftwiuswimuchwit
oowisoon,wiandwiIwimisswiherwisweetwipresencewimorewithanwiwo
rdswicanwisay.wi7ewiessencewiofwiherwiheartwiandwisoulwiiswiwith
wimewialways.wiForwithewiremainingwiSTUB-
Cwifriendswi(Kent,wiDonna,wiPaige,wiJeff,wiJohn,wiBrianna,wiJ
ustin,wiTim,wiCarla,wiandwiJeffwi),withankswiforwiyourwifriends
hip,wiyourwilove,wiandwiyourwiconstancywiinwimywilifewithrough
withewipastwitwowidecades.wiIwicouldn’twiaskwiforwiawibetterwigroup
wiofwipeoplewitowisharewilifewiwith!wiIwihopewitherewiarewimanywimo
rewidecadeswitowicome!
NotwionlywihavewiIwibeenwiblessedwiwithwithesewiincrediblewifrie
nds,wibutwiIwiamwifortunatewitowihavewithewimostwiloving,wicarin
g,wiandwisupportivewihusbandwianywiwomanwicouldwihopewifor.
wiGregwiiswianwiunwaveringwisourcewiofwiencouragementwiandw
iinspireswiandwichallengeswimewitowibewithewibestwiIwicanwibe.wiH
ewihaswistoodwibesidewimewiwithoutwicomplaintwithroughwithewi
dayswiofwiwriter’swiblock,wiloomingwideadlines,wimalfunctionin
gwicomputers,wiandwithewioften-self-
imposedwifrenzywiofwimywiworld.wiHewihaswithewiinsightwitowikn
owwiwhenwitowicheerwimewion,wiwhenwitowimakewimewitakewiawi
break,wiandwiwhenwitowigivewimewispace.wiIwiamwisowigratefulwi
forwihiswicalmingwiinfluence,wihiswiabilitywitowimakewimewilaug
Copyright © 2019 by F. A. Davis Company. All rights reserved. iii
wi wi wi wi wi wi wi wi
Edition by Debra D Sullivan
wi wi wi wi
GUIDE TO
Clinical Document wi
ation
THIRD EDITION
DebrawiD.wiSullivan,wiPhD,wiRN,wiPA-C
Leadw i Advancedw i Practicew i Provider
AcademicwiUrology wi andwiUrogynecology wiofwiAriz
ona wi LitchfieldwiPark,wiAZ
Owner,wiSullivanw i Consultingwi Service
s wi MedicolegalwiConsulting
Glendale,w i AZ
,F.wiA.wiDaviswiCompa
nywi1915wiArchwiStree
t
Philadelphia,wiPAwi191
03wiwww.fadavis.com
Copyrightwi ©wi 2019wi bywi F.wiA.wiDaviswi Company
Copyrightwi©wi2019wibywiF.wiA.wiDaviswiCompany.wiAllwirightswireserved.wiŁiswiproductwiiswiprotectedwibywicopyright.wiNowipa
rtwiofwiitwimaywibewireproduced,wistoredwiinwiawiretrievalwisystem,wiorwitransmittedwiinwianywiformwiorwibywianywimeans,wielectr
onic,wimechanical,wiphotocopying,wirecording,wiorwiotherwise,wiwithoutwiwrittenwipermissionwifromwithewipublisher.
PrintedwiinwithewiUnitedwiStateswiofwiAmerica
Lastwidigitwiindicateswiprintwinumber:wi10wi9wi8wi7wi6wi5wi4wi3wi2wi1
SeniorwiAcquisitionswiEditor:wiMelissawiA.wiDuffield
wiDirectorwiofwiContentwiDevelopment:wiGeorgewiW.wi
LangwiDevelopmentalwiEditor:wiStephaniewiKelly
ArtwiandwiDesignwiManager:wiCarolynwi O’Brien
ContentwiProjectwiManager:wiMeganwiSuermann
Aswinewwiscientificwiinformationwibecomeswiavailablewithroughwibasicwiandwiclinicalwiresearch,wirecommendedwitreatmentswiandwidr
ugwitherapieswiundergowichanges.wiŁewiauthor(s)wiandwipublisherwihavewidonewieverythingwipossiblewitowimakewithiswibookwiaccur
ate,wiupwitowidate,wiandwiinwiaccordwiwithwiacceptedwistandardswiatwithewitimewiofwipublication.wiŁewiauthor(s),wieditors,wiandwipu
blisherwiarewinotwiresponsiblewiforwierrorswiorwiomissionswiorwiforwiconsequenceswifromwiapplicationwiofwithewibook,wiandwimakewi
nowiwarranty,wiexpressedwiorwiimplied,wiinwiregardwitowithewicontentswiofwithewibook.wiAnywipracticewidescribedwiinwithiswibookwi
shouldwibewiappliedwibywithewireaderwiinwiaccordancewiwithwiprofessionalwistandardswiofwicarewiusedwiinwiregardwitowithewiunique
wicircumstanceswithatwimaywiapplywiinwieachwisituation.wiŁewireaderwiiswiadvisedwialwayswitowicheckwiproductwiinformationwi(pack
agewiinserts)wiforwichangeswiandwinewwiinformationwiregardingwidosewiandwicontraindicationswibeforewiadministeringwianywidrug.wi
Cautionwiiswiespeciallywiurgedwiwhenwiusingwinewwiorwiinfrequentlywiorderedwidrugs.
Librarywi ofwi Congresswi Cataloging-in-Publicationwi Data
Names:wi Sullivan,wiDebrawi D.,wiauthor.
Title:wi Guidew i tow i clinicalw i documentation/Debraw i D.wiSullivan.
Description:wiŁirdwiedition.wi|wiPhiladelphia:wiF.A.wiDaviswiCompany,wi
[2019]wi|wiIncludeswibibliographicalwireferenceswiandwiindex.
Identifiers:wiLCCNwi2018019472wi(print)wi|wiLCCNwi2018019898 wi(ebook)wi|wiISBN
wi9780803669994wi|wiISBNwi9780803666627wi(pbk.)
Subjects:wi|wiMESH:wiFormswiandwiRecordswiControl--
methodswi|wiMedicalwiRecords--standards
Classification:wiLCCwiR697.P45wi(ebook)wi|wiLCCwiR697.P45wi(print)wi|wiNLM
wiWwi80wi|wiDDCwi651.5/04261--dc23
LCwi recordwi availablewi atwi https://lccn.loc.gov/2018019472
Authorizationwitowiphotocopywiitemswiforwiinternalwiorwipersonalwiuse,wiorwithewiinternalwiorwipersonalwiusewiofwispecificwiclients,w
iiswigrantedwibywiF.wiA.wiDaviswiCompanywiforwiuserswiregisteredwiwithwithewiCopyrightwiClearancewiCenterwi(CCC)wiTransactiona
lwiReportingwiService,wiprovidedwithatwithewifeewiofwi$.25wiperwicopywiiswipaidwidirectlywitowiCCC,wi222wiRosewoodwiDrive,wiDa
nvers,wiMAwi01923.wiForwithosewiorganizationswithatwihavewibeenwigrantedwiawiphotocopywilicensewibywiCCC,wiawiseparatewisyste
mwiofwipaymentwihaswibeenwiarranged.wiŁewifeewicodewiforwiuserswiofwithewiTransactionalwiReportingwiServicewiis:
978-0-8036-6662-7/18wi0wi+wi$.25.
, Dedication
WhenwiIwithinkwibackwitowi2004,wiwhenwithewifirstwieditionwiofwi
thiswibookwiwaswipublished,wiIwithinkwiofwiawiwonderfulwigrou
pwiofwifriendswiwhowiwerewitherewitowicelebratewiwithwime.wiAswi
Iwianticipatewithewipublicationwiofwithewithirdwiedition,wialmostwi
allwiofwithosewisamewiwonderfulwifriendswiarewistillwihere,wienco
uragingwiandwisupportingwime,wiandwicheeringwimewionwitowithewif
inishwiline.wiSadly,wimywidearwifriendwiCandywileftwiuswimuchwit
oowisoon,wiandwiIwimisswiherwisweetwipresencewimorewithanwiwo
rdswicanwisay.wi7ewiessencewiofwiherwiheartwiandwisoulwiiswiwith
wimewialways.wiForwithewiremainingwiSTUB-
Cwifriendswi(Kent,wiDonna,wiPaige,wiJeff,wiJohn,wiBrianna,wiJ
ustin,wiTim,wiCarla,wiandwiJeffwi),withankswiforwiyourwifriends
hip,wiyourwilove,wiandwiyourwiconstancywiinwimywilifewithrough
withewipastwitwowidecades.wiIwicouldn’twiaskwiforwiawibetterwigroup
wiofwipeoplewitowisharewilifewiwith!wiIwihopewitherewiarewimanywimo
rewidecadeswitowicome!
NotwionlywihavewiIwibeenwiblessedwiwithwithesewiincrediblewifrie
nds,wibutwiIwiamwifortunatewitowihavewithewimostwiloving,wicarin
g,wiandwisupportivewihusbandwianywiwomanwicouldwihopewifor.
wiGregwiiswianwiunwaveringwisourcewiofwiencouragementwiandw
iinspireswiandwichallengeswimewitowibewithewibestwiIwicanwibe.wiH
ewihaswistoodwibesidewimewiwithoutwicomplaintwithroughwithewi
dayswiofwiwriter’swiblock,wiloomingwideadlines,wimalfunctionin
gwicomputers,wiandwithewioften-self-
imposedwifrenzywiofwimywiworld.wiHewihaswithewiinsightwitowikn
owwiwhenwitowicheerwimewion,wiwhenwitowimakewimewitakewiawi
break,wiandwiwhenwitowigivewimewispace.wiIwiamwisowigratefulwi
forwihiswicalmingwiinfluence,wihiswiabilitywitowimakewimewilaug
Copyright © 2019 by F. A. Davis Company. All rights reserved. iii
