,GUIDE TO
Clinical
m
Documentation
THIRD EDITION
m
m
DebramD.mSullivan,mPhD,mRN,mPA-C
LeadmAdvanced m Practice m Pro vider
Academic mUrologymandmUrogynecology mofmArizona mLitchfi
eld m Park, m AZ
Owner,mSullivanm Consulting mServices
m M edico legal m Co nsulting
Glendale,m AZ
,F.mA.mDavis mCompan
ym1915mArchmStreet
Philadelphia,mPA m19103mwww.fadavis.c
om
Copyrightm©m2019mbymF.mA.mDavis mCompany
Copyrightm©m2019mbymF.mA.mDavis mCompany.mAllmrights mreserved.mThis mproductmismprotectedmbymcopyright.mNompartmofmitmmaymbemre
produced,mstoredminmamretrievalmsystem,mormtransmittedminmanymformmormbymanymmeans,melectronic,mmechanical,mphotocopying,mrecord
ing,mormotherwise,mwithoutmwrittenmpermissionmfrommthe mpublisher.
PrintedminmthemUnitedmStates mof mAmerica
Lastmdigitmindicatesmprintmnumber:m10m9 m8m7m6m5 m4m3m2 m1
Senior mAcquisitions mEditor:mMelissamA.mDuffieldmDir
ectormofmContentmDevelopment:mGeorgemW.mLangmDeve
lopmentalmEditor:mStephaniemKelly
ArtmandmDesignmManager:mCarolynmO’Brien
ContentmProjectmManager:mMeganmSuermann
Asmnew mscientificminformationmbecomes mavailablemthroughmbasicmandmclinicalmresearch,mrecommendedmtreatments mandmdrugmtherapiesmu
ndergomchanges.mThemauthor(s)mandmpublishermhavemdonemeverythingmpossiblemtommakemthismbookmaccurate,mupmtomdate,mandminmaccor
dmwithmacceptedmstandards matmthemtimemofmpublication.mThemauthor(s),meditors,mandmpublishermaremnotmresponsiblemformerrors mormomiss
ionsmormformconsequences mfrommapplicationmofmthembook,mandmmakemnomwarranty,mexpressedmormimplied,minmregardmtomthemcontentsmofm
thembook.mAnympracticemdescribedminmthis mbookmshouldmbemappliedmbymthemreaderminmaccordancemwithmprofessionalmstandards mofmcaremu
sedminmregardmtomthemuniquemcircumstances mthatmmaymapplyminmeachmsituation.mThemreadermismadvisedmalways mtomcheckmproductminform
ationm(packageminserts)mformchangesmandmnewminformationmregardingmdosemandmcontraindications mbeforemadministeringmanymdrug.mCaut
ionmis mespeciallymurgedmwhenmusingmnew morminfrequentlymorderedmdrugs.
Librarymofm Congress m Cataloging-in-Publication m Data
Names:mSullivan,mDebramD.,mauthor.
Title:mGuidem tom clinicalm documentation/Debram D.mSullivan.
Description:mThirdmedition.m|mPhiladelphia:mF.A.mDavis mCompany, m[2019]
m|mIncludes mbibliographicalmreferences mand mindex.
Identifiers:mLCCN m2018019472m(print)m|mLCCNm2018019898m(ebook)m|mISBN m97808036
69994m|mISBN m9780803666627m(pbk.)
Subjects:m|mMESH:mForms mandmRecords mControl--
methods m|mMedicalmRecords --standards
Classification:mLCCmR697.P45m(ebook)m|mLCCmR697.P45m(print)m |mNLM mWm80 m|mD
DCm 651.5/04261--dc23
LCmrecordmavailablematmhttps://lccn.loc.gov/2018019472
Authorizationmtomphotocopymitems mforminternalmormpersonalmuse,mormtheminternalmormpersonalmusemofmspecificmclients,mismgrantedmbymF.
mA.mDavis mCompanymformusers mregisteredmwithmthemCopyrightmClearancemCenterm(CCC)mTransactionalmReportingmService,mprovidedmt
hatmthemfeemofm$.25mpermcopymismpaidmdirectlymtomCCC,m222mRosewoodmDrive,mDanvers,mMA m01923.mFormthosemorganizations mthatmha
vembeenmgrantedmamphotocopymlicensembymCCC,mamseparatemsystemmofmpaymentmhasmbeenmarranged.mThemfeemcodemformusers mofmthemT
ransactionalmReportingmServicemis:
978-0-8036-6662-7/18m0m+m$.25.
, Dedication
WhenmImthinkmbackmtom2004,mwhenmthemfirstmeditionmofmthismbo
okmwasmpublished,mImthinkmofmamwonderfulmgroupmofmfriendsm
whomweremthere m to m celebrate m with m me. m As m I manticipate m the mpubli
cationmofm the m third medition, malmostm allmofm those m same m wonderfulm f
riendsmare mstillm here, mencouraging mand m supporting m me, mand mchee
ringmmemonmtomthemfinishmline.mSadly,mmymdearmfriendmCandymlef
tmusmmuchmtoomsoon,mandmImmissm hermsweetmpresencemmoremthan
mwordsmcanmsay.m7emessencemofmhermheartmandmsoulmismwithmmem
always.mFormthemremainingmSTUB-
Cmfriendsm(Kent,mDonna,mPaige,mJeff,mJohn,mBrianna,mJustin
,mTim,mCarla,mandmJeffm),mthanksmformyourmfriendship,myourmlov
e,mandmyourmconstancyminmmymlifemthroughmthempastmtwomdecade
s.mImcouldn’tm ask m for ma m better m group m ofmpeople m to m share m life m with!
I hope m there m are mmany m more mdecades m to m come!
m m
NotmonlymhavemImbeenmblessedmwithmthesemincrediblemfriends,mb
utmImammfortunatemtomhavemthemmostmloving,mcaring,mandmsuppo
rtivemhusbandmanymwomanmcouldmhopemfor.mGregmismanmunwa
veringmsourcemofmencouragement mand m inspires mand mchallenges m
memtombe m thembestmImcanmbe.mHemhasmstoodmbesidemmemwithoutmc
omplaintmthroughmthemdaysmofmwriter’smblock,mloomingmdeadlin
es,mmalfunctioningmcomputers,mandmthemoften-self-
imposedmfrenzymofmmymworld.mHemhasmtheminsightmtomknowmwhe
nmtomcheermmemon,mwhenmtommakemmemtakemambreak,mandmwhen
mtomgivemmemspace.mImam msomgratefulmformhismcalmingminfluenc
e,mhismabilitymtommake
memlaughmand mnotm take m myselfm too m seriously, mand mallm he m does
tomkeepmthingsmrunningm smoothlyminm themSullivanmhousehol
m
d.
Copyrightm©m2019mbymF.mA.mDavis mCompany.mAllmrights mreser iii
ved.
Clinical
m
Documentation
THIRD EDITION
m
m
DebramD.mSullivan,mPhD,mRN,mPA-C
LeadmAdvanced m Practice m Pro vider
Academic mUrologymandmUrogynecology mofmArizona mLitchfi
eld m Park, m AZ
Owner,mSullivanm Consulting mServices
m M edico legal m Co nsulting
Glendale,m AZ
,F.mA.mDavis mCompan
ym1915mArchmStreet
Philadelphia,mPA m19103mwww.fadavis.c
om
Copyrightm©m2019mbymF.mA.mDavis mCompany
Copyrightm©m2019mbymF.mA.mDavis mCompany.mAllmrights mreserved.mThis mproductmismprotectedmbymcopyright.mNompartmofmitmmaymbemre
produced,mstoredminmamretrievalmsystem,mormtransmittedminmanymformmormbymanymmeans,melectronic,mmechanical,mphotocopying,mrecord
ing,mormotherwise,mwithoutmwrittenmpermissionmfrommthe mpublisher.
PrintedminmthemUnitedmStates mof mAmerica
Lastmdigitmindicatesmprintmnumber:m10m9 m8m7m6m5 m4m3m2 m1
Senior mAcquisitions mEditor:mMelissamA.mDuffieldmDir
ectormofmContentmDevelopment:mGeorgemW.mLangmDeve
lopmentalmEditor:mStephaniemKelly
ArtmandmDesignmManager:mCarolynmO’Brien
ContentmProjectmManager:mMeganmSuermann
Asmnew mscientificminformationmbecomes mavailablemthroughmbasicmandmclinicalmresearch,mrecommendedmtreatments mandmdrugmtherapiesmu
ndergomchanges.mThemauthor(s)mandmpublishermhavemdonemeverythingmpossiblemtommakemthismbookmaccurate,mupmtomdate,mandminmaccor
dmwithmacceptedmstandards matmthemtimemofmpublication.mThemauthor(s),meditors,mandmpublishermaremnotmresponsiblemformerrors mormomiss
ionsmormformconsequences mfrommapplicationmofmthembook,mandmmakemnomwarranty,mexpressedmormimplied,minmregardmtomthemcontentsmofm
thembook.mAnympracticemdescribedminmthis mbookmshouldmbemappliedmbymthemreaderminmaccordancemwithmprofessionalmstandards mofmcaremu
sedminmregardmtomthemuniquemcircumstances mthatmmaymapplyminmeachmsituation.mThemreadermismadvisedmalways mtomcheckmproductminform
ationm(packageminserts)mformchangesmandmnewminformationmregardingmdosemandmcontraindications mbeforemadministeringmanymdrug.mCaut
ionmis mespeciallymurgedmwhenmusingmnew morminfrequentlymorderedmdrugs.
Librarymofm Congress m Cataloging-in-Publication m Data
Names:mSullivan,mDebramD.,mauthor.
Title:mGuidem tom clinicalm documentation/Debram D.mSullivan.
Description:mThirdmedition.m|mPhiladelphia:mF.A.mDavis mCompany, m[2019]
m|mIncludes mbibliographicalmreferences mand mindex.
Identifiers:mLCCN m2018019472m(print)m|mLCCNm2018019898m(ebook)m|mISBN m97808036
69994m|mISBN m9780803666627m(pbk.)
Subjects:m|mMESH:mForms mandmRecords mControl--
methods m|mMedicalmRecords --standards
Classification:mLCCmR697.P45m(ebook)m|mLCCmR697.P45m(print)m |mNLM mWm80 m|mD
DCm 651.5/04261--dc23
LCmrecordmavailablematmhttps://lccn.loc.gov/2018019472
Authorizationmtomphotocopymitems mforminternalmormpersonalmuse,mormtheminternalmormpersonalmusemofmspecificmclients,mismgrantedmbymF.
mA.mDavis mCompanymformusers mregisteredmwithmthemCopyrightmClearancemCenterm(CCC)mTransactionalmReportingmService,mprovidedmt
hatmthemfeemofm$.25mpermcopymismpaidmdirectlymtomCCC,m222mRosewoodmDrive,mDanvers,mMA m01923.mFormthosemorganizations mthatmha
vembeenmgrantedmamphotocopymlicensembymCCC,mamseparatemsystemmofmpaymentmhasmbeenmarranged.mThemfeemcodemformusers mofmthemT
ransactionalmReportingmServicemis:
978-0-8036-6662-7/18m0m+m$.25.
, Dedication
WhenmImthinkmbackmtom2004,mwhenmthemfirstmeditionmofmthismbo
okmwasmpublished,mImthinkmofmamwonderfulmgroupmofmfriendsm
whomweremthere m to m celebrate m with m me. m As m I manticipate m the mpubli
cationmofm the m third medition, malmostm allmofm those m same m wonderfulm f
riendsmare mstillm here, mencouraging mand m supporting m me, mand mchee
ringmmemonmtomthemfinishmline.mSadly,mmymdearmfriendmCandymlef
tmusmmuchmtoomsoon,mandmImmissm hermsweetmpresencemmoremthan
mwordsmcanmsay.m7emessencemofmhermheartmandmsoulmismwithmmem
always.mFormthemremainingmSTUB-
Cmfriendsm(Kent,mDonna,mPaige,mJeff,mJohn,mBrianna,mJustin
,mTim,mCarla,mandmJeffm),mthanksmformyourmfriendship,myourmlov
e,mandmyourmconstancyminmmymlifemthroughmthempastmtwomdecade
s.mImcouldn’tm ask m for ma m better m group m ofmpeople m to m share m life m with!
I hope m there m are mmany m more mdecades m to m come!
m m
NotmonlymhavemImbeenmblessedmwithmthesemincrediblemfriends,mb
utmImammfortunatemtomhavemthemmostmloving,mcaring,mandmsuppo
rtivemhusbandmanymwomanmcouldmhopemfor.mGregmismanmunwa
veringmsourcemofmencouragement mand m inspires mand mchallenges m
memtombe m thembestmImcanmbe.mHemhasmstoodmbesidemmemwithoutmc
omplaintmthroughmthemdaysmofmwriter’smblock,mloomingmdeadlin
es,mmalfunctioningmcomputers,mandmthemoften-self-
imposedmfrenzymofmmymworld.mHemhasmtheminsightmtomknowmwhe
nmtomcheermmemon,mwhenmtommakemmemtakemambreak,mandmwhen
mtomgivemmemspace.mImam msomgratefulmformhismcalmingminfluenc
e,mhismabilitymtommake
memlaughmand mnotm take m myselfm too m seriously, mand mallm he m does
tomkeepmthingsmrunningm smoothlyminm themSullivanmhousehol
m
d.
Copyrightm©m2019mbymF.mA.mDavis mCompany.mAllmrights mreser iii
ved.
