Guide to Clinical Documentation 3rd Edition by Debra D Sullivan
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Guide to Clinical Documentation 3rd Edition by Debra D Sullivan
Guide to Clinical Documentation 3rd Edition by Debra D Sullivan
Guide to Clinical Documentation 3rd Edition by Debra D Sullivan
guide to clinical documentation 3rd edition by debra d sullivan
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Guide to Clinical Documentation 3rd Edition by Debra D
Sullivan
GUIDE TO
Clinical
Documentation
THIRD EDITION
Debra D. Sullivan, PhD, RN, PA-C
Lead Advanced Practice Provider
Academic Urology and Urogynecology of Arizona
Litchfield Park, AZ
Owner, Sullivan Consulting Services
Medicolegal Consulting
Glendale, AZ
,
,Acknowledgments
It is interesting to me how each edition of this book bring real-world knowledge and hands-on patient care
has its own uniqueness. I have worked at a different experience where I would only have been able to read
place during the writing of each edition, and I hope and write about what others do.
that has resulted in a deep layering of experience and There is a tremendous team of people at F. A. Davis
knowledge that makes each edition better. I certainly who have been part of this project. Even though he
feel like each job change has enhanced my professional retired before this edition was published, my dear friend
practice and has enriched me as a person. I have met Andy McPhee was the driving (cajoling? bullying?)
and worked with some extraordinary health-care force behind the third edition. I hope he is enjoying
providers, and I have had valuable contributions from his much-deserved retirement and getting to write
so many of them. what he wants, when he wants, if he wants. When
First, I would like to say thank you to my colleagues Andy approached me about a third edition, one of the
at Academic Urology and Urogynecology of Arizona. most anxiety-producing aspects of considering it was
I have had such encouragement and support from this who would be the developmental editor because I had
great group of people. I am grateful to have learned from less-than-wonderful experiences on the two previous
so many outstanding health-care providers throughout editions. I need not have worried at all, as I have had
my more than 27 years in medicine. I have benefitted the very good fortune to work with Stephanie Kelly,
from the expertise of Jamie Bair, NP (cardiology); developmental editor extraordinaire! Stephanie’s
Jennifer Nelson, PA-C (psychiatry); Steve Turner, knowledge of the process, her organizational skills,
RN (hospice); Dr. Richard Guthrie (palliative care); her sense of humor, and her hard work have made the
and several outstanding hospitalists who wished to journey so enjoyable, and she has my deepest gratitude.
remain nameless. I’m thankful for a group of dedicated I’m also grateful for the guidance of and contributions
Information Technology people who have helped me from Melissa Duffield, Senior Acquisitions Editor;
navigate electronic medical records and who’ve answered George Lang, Director of Content Development;
my questions with enthusiasm. Amelia Blevins, Developmental Editor for Digital
I must take this opportunity to acknowledge Products; Megan Suermann, Content Project Manager;
two incredible women who added so much to the Lori Bradshaw, Developmental Production Editor at
Document Library that we included in this edition S4Carlisle Publishing; and Robert Butler, Production
of the book: Madison Palmer, MMS, PA-C, not only Manager. There’s probably not another publishing com-
contributed the prenatal records, but she also provided pany around that would have supported this project as
valuable assistance with content in the prenatal chapter. F. A. Davis has done, and I’m humbled and honored
Larissa J. Bech, MSN, RN, FNP-C contributed the they chose to champion this book.
pediatric records. Without their contributions, the —DEBBIE SULLIvAN
prenatal and pediatric visit notes would not exist. They
vii
, Guide to Clinical Documentation 3rd Edition by Debra D Sullivan
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