Clinical
bf
Documentation
TH IRD t t t
Debra D. Sullivan, PhD, RN, PA-C tb t f t tb t f t tb f t tb f t tb f t
Lead Advanced Practice Provider
tbf t tb tf t t b tf t
Academic Urology and Urogynecology of
t tbf t tbf t tbf t tbf t tbf
ArizonaLitchfield Park, AZ
t b
f tb tf t tbf t
Owner, Sullivan Consulting tb t f t t b t f t
b ServicesMedicolegal Consulting
t f t b
f tb tf t
Glendale, AZ
t tbft
,F. A. Davis Company 1915
t t t t
Arch Street
t t
Philadelphia, PA
t t
19103 www.fadavis.com
t bf
Copyright © 2019 by F. A. Davis Company t t t t t t t
Copyright © 2019 by F. A. Davis Company. All rights reserved. Łis product is protected by copyright. No part of it may be reproduced,
t t t t t t t t t t t t t t t t t t t t t t t
stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,
t t t t t t t t t t t t t t t t t t t t
without written permission from the publisher.
t t t t t t
Printed in the United States of America t t t t t t
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
t t t t t t t t t t t t t t
SeniorAcquisitionsEditor: Melissa A. Duffield
t t t t t
Director of Content Development: George W.
t t t t t t
Lang Developmental Editor:Stephanie Kelly
t bf t t t
Art and Design Manager: Carolyn O’Brien
t t t t t t
Content Project Manager: Megan Suermann
t t t t t
As new scientific information becomes available through basic and clinical research, recommended treatments and drug
t t t t t t t t t t t t t t
therapies undergo changes. Łe author(s) and publisher have done everything possible to make this book accurate, up
t t t t t t t t t t t t t t t t t
to date, and in accord with accepted standards at the time of publication. Łe author(s), editors, and publisher are not
t t t t t t t t t t t t t t t t t t t t
responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or
t t t t t t t t t t t t t t t t t t t
implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance
t t t t t t t t t t t t t t t t t t t t t t t
with professional standards of care used in regard to the unique circumstances that may apply in each situation. Łe reader is
t t t t t t t t t t t t t t t t t t t t t
advised always to check product information (package inserts) for changes and new information regarding dose and contraindications
t t t t t t t t t t t t t t t t t
before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.
t t t t t t t t t t t t t t t
Libraryof Congress Cataloging-in-Publication Data t t t t
Names: Sullivan, Debra D., author. t t t t
Title: Guide to clinical documentation/Debra D. Sullivan. t t t t t t
Description: Łird edition. | Philadelphia: F.A. Davis Company, [2019]
t t t t t t t t t
| Includes bibliographical references and index.
t t t t t
Identifiers: LCCN 2018019472 (print) | LCCN 2018019898 (ebook) | t t t t t t t t
ISBN9780803669994 | ISBN 9780803666627 (pbk.)
t t t t t
Subjects: | MESH: Forms and Records Control--methods | t t t t t t t
Medical Records--standards
t bf
Classification: LCC R697.P45 (ebook) | LCC R697.P45 (print) | NLM W 80 t t t t t t t t t t t
| DDC 651.5/04261--dc23 t t bf
LC record available at https://lccn.loc.gov/2018019472
t t t t
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F.t t t t t t t t t t t t t t t t t t t t t
A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that
t t t t t t t t t t t t t t t t t
the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that
t t t t t t t t t t t t t t t t t t t t t
have been granted a photocopy license by CCC, a separate system of payment has been arranged. Łe fee code for users of the Transactional
t t t t t t t t t t t t t t t t t t t t t t t t
Reporting Service is:
t t t
978-0-8036-6662-7/18 0 + $.25. t t t
, Dedication
WhenIthinkbackto2004,whenthefirsteditionofthisbook was
t t t t t t t t t t t t t
published,I thinkof awonderful group of friendswho were
t t t t t t t t t t t
theretocelebratewithme.AsIanticipatethe publicationofthe
t t t t t t t t t t t
thirdedition,almostallofthosesame wonderfulfriendsa re still
t t t t t t t t t bf t
t here, encouraging and supporting me, and cheering meonto
t t t t t t t t
thefinishline.Sadly,mydear friendCandyleftusmuchtoo soon,
t t t t t t t t t t t t
and I miss her sweet presencemorethanwordscansay.7eessence
t t t t t t t t t t t t
ofherheartandsouliswithmealways.Fortheremaining STUB-
t t t t t t t t t t t t t
C friends (Kent,Donna,Paige,Jeff,John,Brianna,Justin,
t t t t t t t t
Tim,
t
Carla,andJeff),thanksforyourfriendship,yourlove,and your
t t t t t t t t t t t
constancyinmylife throughthepasttwodecades.I couldn’task
t t t t t t t t t t t t
forabettergroupofpeopletosharelife with! Ihope there aremany
t t t t t t t t t t t t t t t
t moredecades to come! t t t
NotonlyhaveIbeenblessedwiththeseincrediblefriends, but I
t t t t t t t t t t bf
amfortunateto havethemost loving,caring,and
t t t t t t t t t
t supportivehusbandanywomancouldhopefor.Gregisan t t t t t t t t
t unwaveringsourceof encouragementandinspiresand t t t t t t
challengesmetobethe best I can be.He has stood beside me
t t t t t t t t t t t t t t
t without complaintthroughthedaysofwriter’sblock,looming t t t t t t t t
deadlines,malfunctioning computers,and the often-self-
t t t t t t t
imposed frenzyofmyworld.Hehastheinsighttoknow whento t t t t t t t t t t t t
cheermeon,whentomakemetakeabreak,and whentogiveme
t t t t t t t t t t t t t t t
space.Iamsogratefulforhiscalming influence,hisabilityto
t t t t t t t t t t t t
make
t
melaugh and nottake myself too seriously,and all he
t t t t t t t t t t
doestokeepthingsrunningsmoothlyintheSullivan
t t t t t t t t t
Copyright © 2019 by F. A. Davis Company. All rights t t t t t t t t t iii
reserved.
t