(Test Bank) Guide to Clinical Documentation

Sullivan, 3

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3rd Edition

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Test Bank for Guide to Clinical Documentation, The downloadable file consists of 417 pages, and the total size of the file is 9.33 MB. Purchase now only for highly discounted price.

Author(s): Sullivan

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Debra o 5 . · ull1van GUIDE TO THIRD EDITION GUIDE TO Clinical Documentation THIRD EDITION Debra D. Sullivan, PhD, RN, PA-C Lead Advanced Practice Provider Academic Urology and Urogynecology of ArizonaLitchfield Park, AZOwner, Sullivan Consulting ServicesMedicolegal ConsultingGlendale, AZ 00_Sullivan_FM.indd 1 7/5/18 5:15 PMF. A. Davis Company 1915 Arch StreetPhiladelphia, PA 19103www.fadavis.com Copyright © 2019 by F. A. Davis Company Copyright © 2019 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of AmericaLast digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Senior Acquisitions Editor: Melissa A. Duffield Director of Content Development: George W. LangDevelopmental Editor: Stephanie KellyArt and Design Manager: Carolyn O’BrienContent Project Manager: Megan Suermann As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Names: Sullivan, Debra D., author. Title: Guide to clinical documentation/Debra D. Sullivan.Description: Third edition. | Philadelphia: F.A. Davis Company, [2019] | Includes bibliogr aphical references and index. Identifiers: LCCN 2018019472 (print) | LCCN 2018019898 (ebook) | ISBN 9780803669994 | ISBN 9780803666627 (pbk.) S ubjects: | MESH: Forms and Records Control--methods | Medical Recor ds--standards Classification: LCC R697.P45 (ebook) | LCC R697.P45 (print) | NLM W 80 | DDC 651.5/04261--dc23 L C record available at https://lccn.loc.gov/2018019472 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is:978-0-8036-6662-7/18 0 + $.25. 00_Sullivan_FM.indd 2 7/5/18 5:15 PMCopyright © 2019 by F. A. Davis Company. All rights reserved. iii Dedication When I think back to 2004, when the first edition of this book was published, I think of a wonderful group of friends who were there to celebrate with me. As I anticipate the publication of the third edition, almost all of those same wonderful friends are still here, encouraging and supporting me, and cheering me on to the finish line. Sadly, my dear friend Candy left us much too soon, and I miss her sweet presence more than words can say. The essence of her heart and soul is with me always. For the remaining STUB-C friends (Kent, Donna, Paige, Jeff, John, Brianna, Justin, Tim, Carla, and Jeff ), thanks for your friendship, your love, and your constancy in my life through the past two decades. I couldn’t ask for a better group of people to share life with! I hope there are many more decades to come! Not only have I been blessed with these incredible friends, but I am fortunate to have the most loving, caring, and supportive husband any woman could hope for. Greg is an unwavering source of encouragement and inspires and challenges me to be the best I can be. He has stood beside me without complaint through the days of writer’s block, looming deadlines, malfunctioning computers, and the often-self-imposed frenzy of my world. He has the insight to know when to cheer me on, when to make me take a break, and when to give me space. I am so grateful for his calming influence, his ability to make me laugh and not take myself too seriously, and all he does to keep things running smoothly in the Sullivan household. Thanks, Greg, for all this, and so much more. And I promise... no fourth edition! 00_Sullivan_FM.indd 3 7/5/18 5:15 PM00_Sullivan_FM.indd 4 7/5/18 5:15 PMCopyright © 2019 by F. A. Davis Company. All rights reserved. v Reviewers Gilbert Boissonneault , PhD, PA-C, DFAAPA Professor Division of Physician Assistant StudiesMedical University of South CarolinaCharleston, SC Elizabeth Brownlee , MPAS, PA-C Physician Assistant, Assistant Professor School of Physician Assistant Studies, College of Medicine University of FloridaGainesville, FL Rhonda Glen Feldman , MHS, MSS, PA-C Program Director Physician AssistantUniversity of New EnglandPortland, ME Pat Kenney-Moore , EdD, PA-C Associate Director/Academic Coordinator/Associate Professor School of Medicine, Division of Physician Assistant EducationOregon Health & Science UniversityPortland, ORSara Haddow Liebel , MSA, PA-C Education Director/Associate ProfessorPhysician Assistant Department, College of Allied Health Sciences Augusta UniversityAugusta, GA Nicole Schmitz , DNP , APRN, PNP , CHSE Assistant Professor NursingMinnesota State University – MankatoMankato, MN Emily K. Sheff , CMSRN, FNP , BC Assistant Professor School of NursingMGH Institute of Health ProfessionsBoston, MA 00_Sullivan_FM.indd 5 7/5/18 5:15 PM00_Sullivan_FM.indd 6 7/5/18 5:15 PMCopyright © 2019 by F. A. Davis Company. All rights reserved. vii Acknowledgments It is interesting to me how each edition of this book has its own uniqueness. I have worked at a different place during the writing of each edition, and I hope that has resulted in a deep layering of experience and knowledge that makes each edition better. I certainly feel like each job change has enhanced my professional practice and has enriched me as a person. I have met and worked with some extraordinary health-care providers, and I have had valuable contributions from so many of them. First, I would like to say thank you to my colleagues at Academic Urology and Urogynecology of Arizona. I have had such encouragement and support from this great group of people. I am grateful to have learned from so many outstanding health-care providers throughout my more than 27 years in medicine. I have benefitted from the expertise of Jamie Bair, NP (cardiology); Jennifer Nelson, PA-C (psychiatry); Steve Turner, RN (hospice); Dr. Richard Guthrie (palliative care); and several outstanding hospitalists who wished to remain nameless. I’m thankful for a group of dedicated Information Technology people who have helped me navigate electronic medical records and who’ve answered my questions with enthusiasm. I must take this opportunity to acknowledge two incredible women who added so much to the Document Library that we included in this edition of the book: Madison Palmer, MMS, PA-C, not only contributed the prenatal records, but she also provided valuable assistance with content in the pr enatal chapter. Larissa J. Bech, MSN, RN, FNP-C contributed the pediatric records. Without their contributions, the prenatal and pediatric visit notes w ould not exist. They bring real-world knowledge and hands-on patient care experience where I would only have been able to read and write about what others do. There is a tremendous team of people at F. A. Davis who have been part of this project. Even though he retired before this edition was published, my dear friend Andy McPhee was the driving (cajoling? bullying?) force behind the third edition. I hope he is enjoying his much-deserved retirement and getting to write what he wants, when he wants, if he wants. When Andy approached me about a third edition, one of the most anxiety-producing aspects of considering it was who would be the developmental editor because I had less-than-wonderful experiences on the two previous editions. I need not have worried at all, as I have had the very good fortune to work with Stephanie Kelly, developmental editor extraordinaire! Stephanie’s knowledge of the process, her organizational skills, her sense of humor, and her hard work have made the journey so enjoyable, and she has my deepest gratitude. I’m also grateful for the guidance of and contributions from Melissa Duffield, Senior Acquisitions Editor; George Lang, Director of Content Development; Amelia Blevins, Developmental Editor for Digital Products; Megan Suermann, Content Project Manager; Lori Bradshaw, Developmental Production Editor at S4Carlisle Publishing; and Robert Butler, Pr oduction Manager. There’s probably not another publishing com - pany around that would have supported this project as F. A. Davis has done, and I’m humbled and honored they chose to champion this book. —Debbie Sullivan 00_Sullivan_FM.indd 7 7/5/18 5:15 PM00_Sullivan_FM.indd 8 7/5/18 5:15 PMCopyright © 2019 by F. A. Davis Company. All rights reserved. ix Brief Contents Part 1: Foundations of Documentation Chapter 1 Medicolegal Principles of Documentation 1 Chapter 2 The Comprehensiv e History and Physical Examination 23 Chapter 3 SOAP Notes 45 Part II: Documentation Related to Outpatient Care Chapter 4 Documenting Prenatal Car e and Perinatal Events 79 Chapter 5 Pediatric Pr eventive Care Visits 93 Chapter 6 Adult Pre ventive Care Visits 125 Chapter 7 Older Adult Pr eventive Care Visits 153 Chapter 8 Outpatient Charting and Comm unication 173 Chapter 9 Prescription Writing and Electronic Prescribing 195 Part III: Documentation Related to Inpatient Care Chapter 10 Admitting a Patient to the Hospital 217 Chapter 11 Documenting Inpatient Care 257 Chapter 12 Discharging Patients fr om the Hospital 285 Appendices Appendix A Document Library 309 Appendix B A Guide to Sexual Histor y T aking 373 Appendix C ISMP’s List of Er ror-Prone Abbreviations, Symbols, and Dose Designations 375 Biblio graphy 377 Index 387 00_Sullivan_FM.indd 9 7/5/18 5:15 PM00_Sullivan_FM.indd 10 7/5/18 5:15 PMCopyright © 2019 by F. A. Davis Company. All rights reserved. xi Contents Part 1: Foundations of Documentation Chapter 1 Medicolegal Principles of Documentation 1 Learning Outcomes 1 Introduction 1 Medical Considerations of Documentation 2 Legal Considerations of Documentation 2 Other Purposes of Documentation 3 General Principles of Documentation 3 Medical Coding and Billing 5 Evaluation and Management Services 5 International Classification of Diseases Coding 6 Electronic Medical Records 8 Benefits of Electronic Medical Records 8 Barriers to Electronic Medical Records 9 Interoperability 9 Meaningful Use 9 Health Insurance Portability and Accountability Act (HIPAA) 10 Health Insurance Portability 10 Electronic Health-Care Transactions 10 The Privacy Rule 10 Security Rule 13 Summary of the Act 14 Summary 14 Worksheets 15 00_Sullivan_FM.indd 11 7/5/18 5:15 PMCopyright © 2019 by F. A. Davis Company. All rights reserved.xii | Contents Chapter 2 The Comprehensiv e History and Physical Examination 23 Learning Outcomes 23 Introduction 23 Components of a Comprehensive History and Physical Examination 23 History 24 Physical Examination 29 Laboratory and Diagnostic Studies 32 Problem List, Assessment, and Differential Diagnosis 32 Plan of Care 32 Sample Comprehensive History and Physical Examination 32 Summary 32 Worksheets 37 Chapter 3 SOAP Notes 45 Learning Outcomes 45 Introduction 45 Subjective 45 Analyzing Documentation 47 Objective 48 Formats for Documenting Objective Information 49 Documenting Diagnostic T est Results 50 Interventions Done During the Visit 50 Assessment 52 Differential Diagnosis 53 Plan 54 Laboratory and Diagnostic T ests 54 Consults 54 Therapeutic Modalities 55 Health Promotion and Disease Prevention 55 Patient Education 55 Follow-Up Instructions 56 Summary 58 Worksheets 59 00_Sullivan_FM.indd 12 7/5/18 5:15 PMCopyright © 2019 by F. A. Davis Company. All rights reserved.Contents | xiii Part II: Documentation Related to Outpatient Care Chapter 4 Documenting Prenatal Car e and Perinatal Events 79 Learning Outcomes 79 Introduction 79 Documentation of Prenatal Care 80 Demographic Information 80 Maternal History 80 Physical Examination 81 Laboratory Data and Diagnostic T ests 82 Health Promotion and Disease Prevention 83 Documentation of Perinatal and Postpartum Care 83 Delivery Note 83 Postpartum Note 86 Newborn Physical Examination 87 Summary 87 Worksheets 89 Chapter 5 Pediatric Pr eventive Care Visits 93 Learning Outcomes 93 Introduction 93 Components of Pediatric Preventive Care Visits 94 Growth Screening 94 Developmental Screening 98 Laboratory Screening T ests 99 Assessing Vaccination Status 100 Anticipatory Guidance 100 Risk Factor Identification 102 Age-Specific Physical Examinations 106 Pediatric Sports Preparticipation Physical Examination 106 Summary 109 Worksheets 111 Chapter 6 Adult Pre ventive Care Visits 125 Learning Outcomes 125 Introduction 125 00_Sullivan_FM.indd 13 7/5/18 5:15 PMCopyright © 2019 by F. A. Davis Company. All rights reserved.Documenting Preventive Care 126 Risk Factor Identification Based on Personal History 126 Risk Factor Identification Based on Family History 135 Risk Factor Identification Based on Screening T ests 135 Gender-Specific Screening 136 Health Education and Counseling 139 Assessing Vaccination Status 139 Summary 139 Worksheets 141 Chapter 7 Older Adult Pr eventive Care Visits 153 Learning Outcomes 153 Introduction 153 Assessing Older Adult Risk Factors Through History T aking 153 Medication Use 153 Functional Impairment 156 Nutrition 156 Sensory Deficit Screening 159 Mental Health Screening 160 Geriatric Syndromes 160 Assessing Older Adult Risk Factors Through Physical Examination 160 Sensory Examinations 161 Balance and Mobility Assessment 162 Cognitive Assessment 162 Additional Screening 162 Pre-operative Evaluation of Older Adults 162 Anticipating Future Needs 165 Advance Directives 165 Hospice and Palliative Care 166 Summary 166 Worksheets 167xiv | Contents 00_Sullivan_FM.indd 14 7/5/18 5:15 PM