,Test Bank for Guide to Clinical Documentation 3rd
p p p p p p p
Edition by Debra D Sullivan
p p p p p
GUIDE TO
Clinical
p
Documentation
p
T H IR D E D I T I O N
p p p p p p p p p p p
Debra D. Sullivan, PhD, RN, PA-C
p p p p p
Lead Advanced Practice Provider
p p p
Academic Urology and Urogynecology of Arizona
p p p p p
Litchfield Park, AZ
p p p
Owner, Sullivan Consulting Services
p p p
Medicolegal Consulting
p p
Glendale, AZ p
,F. pA. pDavis pCompany
p1915 pArch pStreet
Philadelphia, pPA p19103
pwww.fadavis.com
Copyright p © p 2019 p by p F. pA. pDavis p Company
Copyright p© p2019 pby pF. pA. pDavis pCompany. pAll prights preserved. pŁis pproduct pis pprotected pby pcopyright. pNo ppart pof pit pmay pbe
preproduced, p stored pin pa pretrieval psystem, por ptransmitted pin pany pform por pby pany pmeans, pelectronic, pmechanical, pphotocopying,
precording, por potherwise, p without p written p permission pfrom pthe ppublisher.
Printed pin pthe pUnited pStates pof pAmerica
Last pdigit pindicates pprint pnumber: p10 p9 p8 p7 p6 p5 p4 p3 p2 p1
Senior pAcquisitions pEditor: pMelissa pA. pDuffield
pDirector pof pContent pDevelopment: pGeorge pW. pLang
pDevelopmental pEditor: pStephanie pKelly
Art pand pDesign pManager: pCarolyn p O’Brien
Content pProject pManager: pMegan pSuermann
As pnew pscientific pinformation pbecomes pavailable pthrough pbasic pand pclinical presearch, precommended ptreatments pand pdrug ptherapies
pundergo pchanges. pŁe pauthor(s) pand ppublisher phave pdone peverything ppossible pto pmake pthis pbook paccurate, pup pto pdate, pand pin paccord pwith
paccepted pstandards pat pthe ptime pof ppublication. pŁe pauthor(s), peditors, pand ppublisher pare pnot presponsible pfor perrors por pomissions por pfor
pconsequences pfrom papplication pof pthe pbook, pand pmake pno pwarranty, pexpressed por pimplied, pin pregard pto pthe pcontents pof pthe pbook. pAny
ppractice pdescribed pin pthis pbook pshould pbe papplied pby pthe preader pin paccordance pwith pprofessional pstandards pof pcare pused pin pregard pto pthe
punique pcircumstances pthat pmay papply pin peach psituation. pŁe preader pis padvised palways pto pcheck pproduct pinformation p(package pinserts) pfor
pchanges pand pnew pinformation pregarding pdose pand pcontraindications pbefore padministering pany pdrug. pCaution pis pespecially purged pwhen
pusing pnew por pinfrequently pordered pdrugs.
Library p of p Congress p Cataloging-in-Publication p Data
Names: p Sullivan, pDebra p D., pauthor.
Title: p Guide p to p clinical p documentation/Debra p D. pSullivan.
Description: pŁird pedition. p| pPhiladelphia: pF.A. pDavis pCompany, p[2019] p|
pIncludes pbibliographical preferences pand pindex.
Identifiers: pLCCN p2018019472 p(print) p| pLCCN p2018019898 p(ebook) p| pISBN
p9780803669994 p | pISBN p 9780803666627 p(pbk.)
Subjects: p| pMESH: pForms pand pRecords pControl--methods p|
pMedical p Records--standards
Classification: pLCC pR697.P45 p(ebook) p| pLCC pR697.P45 p(print) p| pNLM pW p80 p|
pDDC p 651.5/04261--dc23
LC p record p available p at p https://lccn.loc.gov/2018019472
Authorization pto pphotocopy pitems pfor pinternal por ppersonal puse, por pthe pinternal por ppersonal puse pof pspecific pclients, pis pgranted pby pF. pA.
pDavis pCompany pfor pusers pregistered pwith pthe pCopyright pClearance pCenter p(CCC) pTransactional pReporting pService, pprovided pthat pthe pfee
pof p$.25 pper pcopy pis ppaid pdirectly pto pCCC, p222 pRosewood pDrive, pDanvers, pMA p01923. pFor pthose porganizations pthat phave pbeen pgranted pa
pphotocopy plicense pby pCCC, pa pseparate psystem pof ppayment phas pbeen parranged. pŁe pfee pcode pfor pusers pof pthe pTransactional pReporting
pService pis:
978-0-8036-6662-7/18 p0 p+ p$.25.
, Dedication
When I think back to 2004, when the first edition of this book
p p p p p p p p p p p p
p was published, I think of a wonderful group of friends who
p p p p p p p p p p
p were there to celebrate with me. As I anticipate the publication
p p p p p p p p p p
p of the third edition, almost all of those same wonderful friends
p p p p p p p p p p
p are still here, encouraging and supporting me, and cheering me
p p p p p p p p p
p on to the finish line. Sadly, my dear friend Candy left us much
p p p p p p p p p p p p
p too soon, and I miss her sweet presence more than words can
p p p p p p p p p p p
p say. 7e essence of her heart and soul is with me always. For
p p p p p p p p p p p p
p the remaining STUB-C friends (Kent, Donna, Paige, Jeff,
p p p p p p p
p John, Brianna, Justin, Tim, Carla, and Jeff ), thanks for your
p p p p p p p p p p
p friendship, your love, and your constancy in my life through
p p p p p p p p p
p the past two decades. I couldn’t ask for a better group of people
p p p p p p p p p p p p
p to share life with! I hope there are many more decades to come!
p p p p p p p p p p p p
Not only have I been blessed with these incredible friends, but I
p p p p p p p p p p p
am fortunate to have the most loving, caring, and supportive
p p p p p p p p p p
p husband any woman could hope for. Greg is an unwavering
p p p p p p p p p
p source of encouragement and inspires and challenges me to be
p p p p p p p p p
p the best I can be. He has stood beside me without complaint
p p p p p p p p p p p
p through the days of writer’s block, looming deadlines,
p p p p p p p
p malfunctioning computers, and the often-self-imposed frenzy p p p p p
p of my world. He has the insight to know when to cheer me on,
p p p p p p p p p p p p p
p when to make me take a break, and when to give me space. I
p p p p p p p p p p p p p
p am so grateful for his calming influence, his ability to make
p p p p p p p p p p
p me laugh and not take myself too seriously, and all he does
p p p p p p p p p p p
to keep things running smoothly in the Sullivan household.
p p p p p p p p
p 7anks, Greg, for all this, and so much more. And I promise...
p p p p p p p p p p p
p no fourth edition!
p p
Copyright p © p 2019 p by p F. pA. pDavis p Company. pAll p rights iii
p reserved.
p p p p p p p
Edition by Debra D Sullivan
p p p p p
GUIDE TO
Clinical
p
Documentation
p
T H IR D E D I T I O N
p p p p p p p p p p p
Debra D. Sullivan, PhD, RN, PA-C
p p p p p
Lead Advanced Practice Provider
p p p
Academic Urology and Urogynecology of Arizona
p p p p p
Litchfield Park, AZ
p p p
Owner, Sullivan Consulting Services
p p p
Medicolegal Consulting
p p
Glendale, AZ p
,F. pA. pDavis pCompany
p1915 pArch pStreet
Philadelphia, pPA p19103
pwww.fadavis.com
Copyright p © p 2019 p by p F. pA. pDavis p Company
Copyright p© p2019 pby pF. pA. pDavis pCompany. pAll prights preserved. pŁis pproduct pis pprotected pby pcopyright. pNo ppart pof pit pmay pbe
preproduced, p stored pin pa pretrieval psystem, por ptransmitted pin pany pform por pby pany pmeans, pelectronic, pmechanical, pphotocopying,
precording, por potherwise, p without p written p permission pfrom pthe ppublisher.
Printed pin pthe pUnited pStates pof pAmerica
Last pdigit pindicates pprint pnumber: p10 p9 p8 p7 p6 p5 p4 p3 p2 p1
Senior pAcquisitions pEditor: pMelissa pA. pDuffield
pDirector pof pContent pDevelopment: pGeorge pW. pLang
pDevelopmental pEditor: pStephanie pKelly
Art pand pDesign pManager: pCarolyn p O’Brien
Content pProject pManager: pMegan pSuermann
As pnew pscientific pinformation pbecomes pavailable pthrough pbasic pand pclinical presearch, precommended ptreatments pand pdrug ptherapies
pundergo pchanges. pŁe pauthor(s) pand ppublisher phave pdone peverything ppossible pto pmake pthis pbook paccurate, pup pto pdate, pand pin paccord pwith
paccepted pstandards pat pthe ptime pof ppublication. pŁe pauthor(s), peditors, pand ppublisher pare pnot presponsible pfor perrors por pomissions por pfor
pconsequences pfrom papplication pof pthe pbook, pand pmake pno pwarranty, pexpressed por pimplied, pin pregard pto pthe pcontents pof pthe pbook. pAny
ppractice pdescribed pin pthis pbook pshould pbe papplied pby pthe preader pin paccordance pwith pprofessional pstandards pof pcare pused pin pregard pto pthe
punique pcircumstances pthat pmay papply pin peach psituation. pŁe preader pis padvised palways pto pcheck pproduct pinformation p(package pinserts) pfor
pchanges pand pnew pinformation pregarding pdose pand pcontraindications pbefore padministering pany pdrug. pCaution pis pespecially purged pwhen
pusing pnew por pinfrequently pordered pdrugs.
Library p of p Congress p Cataloging-in-Publication p Data
Names: p Sullivan, pDebra p D., pauthor.
Title: p Guide p to p clinical p documentation/Debra p D. pSullivan.
Description: pŁird pedition. p| pPhiladelphia: pF.A. pDavis pCompany, p[2019] p|
pIncludes pbibliographical preferences pand pindex.
Identifiers: pLCCN p2018019472 p(print) p| pLCCN p2018019898 p(ebook) p| pISBN
p9780803669994 p | pISBN p 9780803666627 p(pbk.)
Subjects: p| pMESH: pForms pand pRecords pControl--methods p|
pMedical p Records--standards
Classification: pLCC pR697.P45 p(ebook) p| pLCC pR697.P45 p(print) p| pNLM pW p80 p|
pDDC p 651.5/04261--dc23
LC p record p available p at p https://lccn.loc.gov/2018019472
Authorization pto pphotocopy pitems pfor pinternal por ppersonal puse, por pthe pinternal por ppersonal puse pof pspecific pclients, pis pgranted pby pF. pA.
pDavis pCompany pfor pusers pregistered pwith pthe pCopyright pClearance pCenter p(CCC) pTransactional pReporting pService, pprovided pthat pthe pfee
pof p$.25 pper pcopy pis ppaid pdirectly pto pCCC, p222 pRosewood pDrive, pDanvers, pMA p01923. pFor pthose porganizations pthat phave pbeen pgranted pa
pphotocopy plicense pby pCCC, pa pseparate psystem pof ppayment phas pbeen parranged. pŁe pfee pcode pfor pusers pof pthe pTransactional pReporting
pService pis:
978-0-8036-6662-7/18 p0 p+ p$.25.
, Dedication
When I think back to 2004, when the first edition of this book
p p p p p p p p p p p p
p was published, I think of a wonderful group of friends who
p p p p p p p p p p
p were there to celebrate with me. As I anticipate the publication
p p p p p p p p p p
p of the third edition, almost all of those same wonderful friends
p p p p p p p p p p
p are still here, encouraging and supporting me, and cheering me
p p p p p p p p p
p on to the finish line. Sadly, my dear friend Candy left us much
p p p p p p p p p p p p
p too soon, and I miss her sweet presence more than words can
p p p p p p p p p p p
p say. 7e essence of her heart and soul is with me always. For
p p p p p p p p p p p p
p the remaining STUB-C friends (Kent, Donna, Paige, Jeff,
p p p p p p p
p John, Brianna, Justin, Tim, Carla, and Jeff ), thanks for your
p p p p p p p p p p
p friendship, your love, and your constancy in my life through
p p p p p p p p p
p the past two decades. I couldn’t ask for a better group of people
p p p p p p p p p p p p
p to share life with! I hope there are many more decades to come!
p p p p p p p p p p p p
Not only have I been blessed with these incredible friends, but I
p p p p p p p p p p p
am fortunate to have the most loving, caring, and supportive
p p p p p p p p p p
p husband any woman could hope for. Greg is an unwavering
p p p p p p p p p
p source of encouragement and inspires and challenges me to be
p p p p p p p p p
p the best I can be. He has stood beside me without complaint
p p p p p p p p p p p
p through the days of writer’s block, looming deadlines,
p p p p p p p
p malfunctioning computers, and the often-self-imposed frenzy p p p p p
p of my world. He has the insight to know when to cheer me on,
p p p p p p p p p p p p p
p when to make me take a break, and when to give me space. I
p p p p p p p p p p p p p
p am so grateful for his calming influence, his ability to make
p p p p p p p p p p
p me laugh and not take myself too seriously, and all he does
p p p p p p p p p p p
to keep things running smoothly in the Sullivan household.
p p p p p p p p
p 7anks, Greg, for all this, and so much more. And I promise...
p p p p p p p p p p p
p no fourth edition!
p p
Copyright p © p 2019 p by p F. pA. pDavis p Company. pAll p rights iii
p reserved.
