,TestBankforGuidetoClinicalDocumentation3rdEdition
byDebraDSullivan
GUIDETO
ClinicalDocumenta
tion
THIRDEDITION
DebraD.Sullivan,PhD,RN,PA-C
LeadAdvancedPracticeProvider
AcademicUrologyandUrogynecologyofArizonaLitchfi
eldPark,AZ
Owner,SullivanConsultingServicesMedic
olegalConsulting
Glendale,AZ
,F.A.DavisCompany19
15ArchStreet
Philadelphia,PA1910
3www.fadavis.com
Copyright©2019byF.A.DavisCompany
Copyright©2019byF.A.DavisCompany.Allrightsreserved.Łisproductisprotectedbycopyright.Nopartofitmaybereproduced,storedinar
etrievalsystem,ortransmittedinanyformorbyanymeans,electronic,mechanical,photocopying
,recording,orotherwise,withoutwrittenpermissionfromthepublisher.Printedinthe
UnitedStatesofAmerica
Lastdigitindicatesprintnumber:10987654321
SeniorAcquisitionsEditor:MelissaA.DuffieldDirectorof
ContentDevelopment:GeorgeW.LangDevelopmentalEd
itor:StephanieKelly
ArtandDesignManager:CarolynO’Brien
ContentProjectManager:MeganSuermann
Asnewscientificinformationbecomesavailablethroughbasicandclinicalresearch,recommendedtreatmentsanddrugtherapiesundergochanges.Ł
eauthor(s)andpublisherhavedoneeverythingpossibletomakethisbookaccurate,uptodate,andinaccordwithacceptedstandardsatthetimeofpublic
ation.Łeauthor(s),editors,andpublisherarenotresponsibleforerrorsoromissionsorforconsequencesfromapplicationofthebook,andmakenowarr
anty,expressedorimplied,inregardtothecontentsofthebook.Anypracticedescribedinthisbookshouldbeappliedbythereaderinaccordancewithpr
ofessionalstandardsofcareusedinregardtotheuniquecircumstancesthatmayapplyineachsituation.Łereaderisadvisedalwaystocheckproductinfo
rmation(packageinserts)forchangesandnewinformationregardingdoseandcontraindicationsbeforeadministeringanydrug.Cautionisespecially
urgedwhenusingneworinfrequentlyordereddrugs.
LibraryofCongressCataloging-in-PublicationData
Names:Sullivan,DebraD.,author.
Title:Guidetoclinicaldocumentation/DebraD.Sullivan.
Description:Łirdedition.|Philadelphia:F.A.DavisCompany,[2019]|Includesbib
liographicalreferencesandindex.
Identifiers:LCCN2018019472(print)|LCCN2018019898(ebook)|ISBN9780803669994|IS
BN9780803666627(pbk.)
Subjects:|MESH:FormsandRecordsControl--
methods|MedicalRecords--standards
Classification:LCCR697.P45(ebook)|LCCR697.P45(print)|NLMW80|DDC651.5/04
261--dc23
LCrecordavailableathttps://lccn.loc.gov/2018019472
Authorizationtophotocopyitemsforinternalorpersonaluse,ortheinternalorpersonaluseofspecificclients,isgrantedbyF
.A.DavisCompanyforusersregisteredwiththeCopyrightClearanceCenter(CCC)TransactionalReportingService,providedthatthefeeof$.25perc
opyispaiddirectlytoCCC,222RosewoodDrive,Danvers,MA01923.ForthoseorganizationsthathavebeengrantedaphotocopylicensebyCCC,ase
paratesystemofpaymenthasbeenarranged.ŁefeecodeforusersoftheTransactionalReportingServiceis:
978-0-8036-6662-7/180+$.25.
, Dedication
WhenIthinkbackto2004,whenthefirsteditionofthisbookwasp
ublished,Ithinkofawonderfulgroupoffriendswhoweretheret
ocelebratewithme.AsIanticipatethepublicationofthethirdedi
tion,almostallofthosesamewonderfulfriendsarestillhere,enco
uragingandsupportingme,andcheeringmeontothefinishline.S
adly,mydearfriendCandyleftusmuchtoosoon,andImisshers
weetpresencemorethanwordscansay.7eessenceofherhearta
ndsouliswithmealways.FortheremainingSTUB-
Cfriends(Kent,Donna,Paige,Jeff,John,Brianna,Justin
,Tim,Carla,andJeff),thanksforyourfriendship,yourlove,an
dyourconstancyinmylifethroughthepasttwodecades.Icouldn
’taskforabettergroupofpeopletosharelifewith!Ihopethereare
manymoredecadestocome!
NotonlyhaveIbeenblessedwiththeseincrediblefriends,butIa
mfortunatetohavethemostloving,caring,andsupportivehusb
andanywomancouldhopefor.Gregisanunwaveringsourceofe
ncouragementandinspiresandchallengesmetobethebestIcan
be.Hehasstoodbesidemewithoutcomplaintthroughthedaysof
writer’sblock,loomingdeadlines,malfunctioningcomputers,
andtheoften-self-
imposedfrenzyofmyworld.Hehastheinsighttoknowwhentoch
eermeon,whentomakemetakeabreak,andwhentogivemespac
e.Iamsogratefulforhiscalminginfluence,hisabilitytomakeme
laughandnottakemyselftooseriously,andallhedoes
tokeepthingsrunningsmoothlyintheSullivanhousehold.
7anks,Greg,forallthis,andsomuchmore.AndIpromis
Copyright©2019byF.A.DavisCompany.Allrightsres iii
byDebraDSullivan
GUIDETO
ClinicalDocumenta
tion
THIRDEDITION
DebraD.Sullivan,PhD,RN,PA-C
LeadAdvancedPracticeProvider
AcademicUrologyandUrogynecologyofArizonaLitchfi
eldPark,AZ
Owner,SullivanConsultingServicesMedic
olegalConsulting
Glendale,AZ
,F.A.DavisCompany19
15ArchStreet
Philadelphia,PA1910
3www.fadavis.com
Copyright©2019byF.A.DavisCompany
Copyright©2019byF.A.DavisCompany.Allrightsreserved.Łisproductisprotectedbycopyright.Nopartofitmaybereproduced,storedinar
etrievalsystem,ortransmittedinanyformorbyanymeans,electronic,mechanical,photocopying
,recording,orotherwise,withoutwrittenpermissionfromthepublisher.Printedinthe
UnitedStatesofAmerica
Lastdigitindicatesprintnumber:10987654321
SeniorAcquisitionsEditor:MelissaA.DuffieldDirectorof
ContentDevelopment:GeorgeW.LangDevelopmentalEd
itor:StephanieKelly
ArtandDesignManager:CarolynO’Brien
ContentProjectManager:MeganSuermann
Asnewscientificinformationbecomesavailablethroughbasicandclinicalresearch,recommendedtreatmentsanddrugtherapiesundergochanges.Ł
eauthor(s)andpublisherhavedoneeverythingpossibletomakethisbookaccurate,uptodate,andinaccordwithacceptedstandardsatthetimeofpublic
ation.Łeauthor(s),editors,andpublisherarenotresponsibleforerrorsoromissionsorforconsequencesfromapplicationofthebook,andmakenowarr
anty,expressedorimplied,inregardtothecontentsofthebook.Anypracticedescribedinthisbookshouldbeappliedbythereaderinaccordancewithpr
ofessionalstandardsofcareusedinregardtotheuniquecircumstancesthatmayapplyineachsituation.Łereaderisadvisedalwaystocheckproductinfo
rmation(packageinserts)forchangesandnewinformationregardingdoseandcontraindicationsbeforeadministeringanydrug.Cautionisespecially
urgedwhenusingneworinfrequentlyordereddrugs.
LibraryofCongressCataloging-in-PublicationData
Names:Sullivan,DebraD.,author.
Title:Guidetoclinicaldocumentation/DebraD.Sullivan.
Description:Łirdedition.|Philadelphia:F.A.DavisCompany,[2019]|Includesbib
liographicalreferencesandindex.
Identifiers:LCCN2018019472(print)|LCCN2018019898(ebook)|ISBN9780803669994|IS
BN9780803666627(pbk.)
Subjects:|MESH:FormsandRecordsControl--
methods|MedicalRecords--standards
Classification:LCCR697.P45(ebook)|LCCR697.P45(print)|NLMW80|DDC651.5/04
261--dc23
LCrecordavailableathttps://lccn.loc.gov/2018019472
Authorizationtophotocopyitemsforinternalorpersonaluse,ortheinternalorpersonaluseofspecificclients,isgrantedbyF
.A.DavisCompanyforusersregisteredwiththeCopyrightClearanceCenter(CCC)TransactionalReportingService,providedthatthefeeof$.25perc
opyispaiddirectlytoCCC,222RosewoodDrive,Danvers,MA01923.ForthoseorganizationsthathavebeengrantedaphotocopylicensebyCCC,ase
paratesystemofpaymenthasbeenarranged.ŁefeecodeforusersoftheTransactionalReportingServiceis:
978-0-8036-6662-7/180+$.25.
, Dedication
WhenIthinkbackto2004,whenthefirsteditionofthisbookwasp
ublished,Ithinkofawonderfulgroupoffriendswhoweretheret
ocelebratewithme.AsIanticipatethepublicationofthethirdedi
tion,almostallofthosesamewonderfulfriendsarestillhere,enco
uragingandsupportingme,andcheeringmeontothefinishline.S
adly,mydearfriendCandyleftusmuchtoosoon,andImisshers
weetpresencemorethanwordscansay.7eessenceofherhearta
ndsouliswithmealways.FortheremainingSTUB-
Cfriends(Kent,Donna,Paige,Jeff,John,Brianna,Justin
,Tim,Carla,andJeff),thanksforyourfriendship,yourlove,an
dyourconstancyinmylifethroughthepasttwodecades.Icouldn
’taskforabettergroupofpeopletosharelifewith!Ihopethereare
manymoredecadestocome!
NotonlyhaveIbeenblessedwiththeseincrediblefriends,butIa
mfortunatetohavethemostloving,caring,andsupportivehusb
andanywomancouldhopefor.Gregisanunwaveringsourceofe
ncouragementandinspiresandchallengesmetobethebestIcan
be.Hehasstoodbesidemewithoutcomplaintthroughthedaysof
writer’sblock,loomingdeadlines,malfunctioningcomputers,
andtheoften-self-
imposedfrenzyofmyworld.Hehastheinsighttoknowwhentoch
eermeon,whentomakemetakeabreak,andwhentogivemespac
e.Iamsogratefulforhiscalminginfluence,hisabilitytomakeme
laughandnottakemyselftooseriously,andallhedoes
tokeepthingsrunningsmoothlyintheSullivanhousehold.
7anks,Greg,forallthis,andsomuchmore.AndIpromis
Copyright©2019byF.A.DavisCompany.Allrightsres iii
