Guide to Clinical Documentation

301 Pages·2011·6.284 MB·English

by  Debra D. Sullivan

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Guide to
Clinical Documentation
Second Edition
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Guide to
Clinical Documentation
Second Edition
Debra D. Sullivan, PhD, RN, PA-C
Nurse Consultant, Risk Management
Banner Health
Phoenix, AZ
Clinical Adjunct Faculty,Associate Professor
Midwestern University
Arizona College of Osteopathic Medicine
Glendale, AZ
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Last digit indicates print number:10 9 8 7 6 5 4 3 2 1
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Manager ofContent Development:George W.Lang
Developmental Editor:Nancy Hoffman
Design and Illustration Manager:Carolyn O’Brien
As new scientific information becomes available through basic and clinical research,recommended treatments and drug therapies under-
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Library of Congress Cataloging-in-Publication Data
Sullivan,Debra D.
Guide to clinical documentation / Debra D.Sullivan.— 2nd ed.
p.;cm.
Rev.ed.of:Documentation for physician assistants / Debra D.Sullivan,Lynnette J.Mattingly.c2004.
Includes bibliographical references and index.
ISBN-13:978-0-8036-2583-9
ISBN-10:0-8036-2583-9
1. Physicians’assistants.2. Medical records.3. Medical protocols. I.Sullivan,Debra D.Documentation for physician assistants.II.
Title.
[DNLM:1. Forms and Records Control—methods.2. Medical Records—standards. W 80]
R697.P45S85 2012
651.5’04261—dc22
2011014762
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8036-2583-9//12 0 + $.25.
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Dedication
It is an honor to dedicate this book to two very
special women.First,to Dr.Tracy O.Middleton,
who embodies professionalism,caring,compassion,
and the ability to multitask.The sheer number
of SOAP notes,histories and physicals,and other
forms of documentation Tracy has read over
the years in her roles of teacher,physician,
colleague,mentor,and friend would stagger us
all.Dr.Middleton has positively affected literally
hundreds of health-care professionals,and I am
fortunate to be one of them.
There is a saying that you can’t pick your
parents;if I could have chosen,I would still choose
the ones God chose for me.I’m blessed beyond
measure to have Louise Howard Dover as my
mother.As a nurse,she has helped me with this
book in several ways,and I’m always grateful for
help. As a woman,she is the epitome of selflessness,
humility,and compassion.As a mother,she has
always encouraged me and challenged me to be my
best.Thanks for everything,Mom.
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Reviewers
GILBERT A.BOISSONNEAULT,PHD,PA-C PETER D.KUEMMEL,MS,RPA-C
Professor Clinical Associate Professor,Vice Chair
Clinical Sciences Physician Assistant Education
University of Kentucky Stony Brook University
Lexington,Kentucky Stony Brook,New York
CHRISTOPHER K.COOPER,MPAS,PA-C MARY ANN LAXEN,MAB,FNP,PA-C
Instructor Program Director,Retired
Medical Education Physician Assistant Department
University of North Texas Health Science Center University of North Dakota
Fort Worth,Texas Grand Forks,North Dakota
ERICH A.FOGG,PA-C,MMSC NORA LOWRY,MPA,PA-C
Program Director Program Director
Physician Assistant Department Physician Assistant Department
University of New England Wagner College
Portland,Maine Staten Island,New York
SARA HADDOW,MSA,PA-C CHERYL MOREDICH,RN,MS,WHNP-BC
Education Director,Assistant Professor Associate Professor
Physician Assistant Department Nursing
Medical College of Georgia Purdue University
Augusta,Georgia West Lafayette,Indiana
JOANNE HAEFFELE,PHD DIANE E.NUÑEZ,RN,MS,ANP,BC
Assistant Professor Clinical Associate Professor
Nurse Practitioner Faculty College of Nursing & Healthcare Innovation
University of Utah College of Nursing Arizona State University
Salt Lake City,Utah Tempe,Arizona
JOELLEN W.HAWKINS,RNC,PHD,FAAN, MICHELE ROTH-KAUFFMAN,JD,MPAS,
FAANP PA-C
Professor Emerita Associate Dean & Chair
William F.Connell School of Nursing Physician Assistant Department
Boston College Gannon University
Chestnut Hill,Massachusetts Erie,PA
PAT KENNEY-MOORE,MS,PA-C BARBARA L.SAULS,EDD,PA-C
Associate Professor,Associate Director, Clinical Professor
Academic Coordinator Physician Assistant Studies
Division of Physician Assistant Education King’s College
Oregon Health & Science University Wilkes-Barre,Pennsylvania
Portland,Oregon
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viii | Reviewers
EMILY K.SHEFF,CMSRN,FNP,BC CHIKA UGORJI,MD
Family Nurse Practitioner Community Pediatrics
School of Nursing University of Florida
MGH Institute of Health Professions Jacksonville,Florida
Boston,Massachusetts
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Acknowledgments
From the very beginning stages of the first edition I’m also greatful to Sheila Carvalho for lending fresh
through every page of the second,I’ve had the unwa- eyes to the proofreading process. I’m indebted to
vering support of my husband,Greg.Not only did he Meritza Santamaria-Hoffman,RN,JD,not only for
take on dish duty,grocery shopping,and other mis- reviewing sections of the text,but for being a tremen-
cellaneous chores,but he has also pitched in as proof- dous encourager and fantastic boss,and for introduc-
reader,cheerleader,advisor,and sounding board. ing me to the world of risk management. These
I’ve spent many years in my life being a student. strong and capable women have blessed me beyond
From nursing school,to PA school,and through my measure
master’s and doctorate programs, I have been fortu- There are so many people at F.A.Davis who were
nate to learn from some of the best. So, I take this a part of this project. First and foremost, thanks to
opportunity to say a heartfelt thanks to them,and to Andy McPhee, for having a vision and helping to
teachers everywhere, for the amazing work they do. make it reality.I appreciate Nancy Hoffman and her
I’ve also known and worked with so many bright,car- work as developmental editor, and all the help and
ing, and truly gifted medical professionals over the guidance along the way to keep things moving
years and several careers.They deserve far more thanks forward. I extend my gratitude to George Lang,
than I can express here.There are too many to ment- Manager of Content Development at F. A. Davis,
ion by name, but I must acknowledge Kristin Neal, for his work on the manuscript,and to Sharon Lee,
MPH,PA-C and Lynnette Mattingly,MHPE,PA-C Production Manager.This is truly a team effort!
for their work as contributing authors, their years
—DEBBIE SULLIVAN
of friendship, and the laughter of girls night out!
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