Guide to Clinical Documentation 3rd Edition Debra Sullivan.

,GUIDE TO bf




Documentation b
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Debra bgb b g f b g D. bgb b g f b g Sullivan, PhD, RN, PA-C gb f bg gb f bg gb f bg




Lead Advanced Practice Provider
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Academic Urology and Urogynecology
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of ArizonaLitchfield Park, AZ
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Owner, Sullivan Consulting
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b ServicesMedicolegal
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Consulting Glendale, AZ
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,F. A. Davis Company
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1915 Arch Street
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Philadelphia, PA
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19103 www.fadavis.com
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Copyright b g © b g 2019 b g by b g F. A. Davis
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Copyright © 2019 by F. A. Davis Company. All rights reserved. Łis product is protected by copyright. No part of it may be
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reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying,
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recording, or otherwise, without written permission from the publisher.
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Printed in the United States of America
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Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
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Senior Acquisitions Editor: Melissa A. Duffield
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Director of Content Development: George
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W. Lang Developmental Editor: Stephanie
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Carolyn O’Brien Content Project
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Manager: Megan Suermann
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As new scientific information becomes available through basic and clinical research, recommended treatments
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and drug therapies undergo changes. Łe author(s)
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b make
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publication. Łe author(s), editors, and publisher are not responsible for errors or omissions or for consequences
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from application of the book, and make no warranty, expressed or implied, in regard to the contents of the
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book. Any practice described in this book should be applied by the reader in accordance with professional
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standards of care used in regard to the unique circumstances that may apply in each situation. Łe reader
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is advised always to check product information (package inserts) for changes and new information regarding dose and
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contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered
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drugs.
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Library of Congress Cataloging-in-Publication Data
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Names: Sullivan, Debra D., author. b g bg b g bg


Title: Guide to clinical documentation/Debra D. Sullivan.
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Description: Łird edition. | Philadelphia: F.A. Davis Company,
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[2019]
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| Includes bibliographical references and index.
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Identifiers: LCCN 2018019472 (print) | LCCN 2018019898 (ebook) |
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ISBN9780803669994 | ISBN 9780803666627 (pbk.)
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Subjects: | MESH: Forms and Records Control-- bg bg bg b g b g b g


methods | Medical Records--standards b g bg bf


Classification: LCC R697.P45 (ebook) | LCC R697.P45 (print) | b g b g b g b g b g b g b g b g


NLM W 80 | DDC 651.5/04261--dc23
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LC record bavailable
g at https://lccn.loc.gov/2018019472 b g b g b g




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Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222
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CCC, a separate system of payment has been arranged. Łe fee code for users of the Transactional Reporting Service is:
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978-0-8036-6662-7/18 0 + $.25. bg bg b g

, Dedication




When I think back to 2004, when the first edition of this book
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bg was published, I think of a wonderful group of friends who
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bg were there to celebrate with me.As I anticipate the
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bg publicationof the third edition, almost all of those same bg bg bg bg bg bg bg bg




bg wonderful friendsare still here, encouraging and bg bf bg b g bg bg




bg supporting me, and cheering meon to the finish line. bg bg bg bg bg bg bg bg




bg Sadly, my dear friend Candy left us muchtoo soon, and I
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bg miss her sweet presence more than words can say.7e
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bg essence of her heart and soul is with me always.For the
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bg remaining STUB-C friends (Kent, Donna, Paige, Jeff, bg bg bg bg bg bg




bg John, Brianna, Justin, Tim, bg bg bg




Carla, and Jeff ), thanks for your friendship, your love, and
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bg your constancy in my life through the past two decades.I
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bg couldn’t ask for a better group of people to share life with! I
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bg hope there are many more decades to come!
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Not only have I been blessed with these incredible friends,
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bg but I am fortunate to have the most loving, caring, and
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bg supportivehusband any woman could hope for. Greg is an bg bg bg bg bg bg bg bg




bg unwavering source of encouragement and inspires and bg bg bg bg bg bg




bg challenges me to be the best I can be. He has stood beside bg bg bg bg bg bg bg bg bg bg bg bg




bg me without complaint through the days of writer’s block,
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looming deadlines, malfunctioning computers, and the
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bg often- self-imposed frenzy of my world. He has the insight to
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know when to cheer me on, when to make me take a break,
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and when to give me space. I am so grateful for his calming
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bg influence,his ability to make bg bg bg bg




me laugh and not take myself too seriously, and all
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he does to keep things running smoothly in the
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Copyright © 2019 by b g b g b g b g F. A. Davis bg bg b g Company.
All rights reserved.
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