Debra GUIDE TO THIRD EDITION o· ull1van 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 Ser vices Medicolegal Consulting Glendale, AZ 00_Sullivan_FM.indd 7/5/18 5:15 PM F A Davis Company 1915 Arch Street Philadelphia, PA 19103 www.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 America Last digit indicates print number: 10 Senior Acquisitions Editor: Melissa A Duffield Director of Content Development: George W Lang Developmental Editor: Stephanie Kelly Art and Design Manager: Carolyn O’Brien Content 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 bibliographical references and index Identifiers: LCCN 2018019472 (print) | LCCN 2018019898 (ebook) | ISBN 9780803669994 | ISBN 9780803666627 (pbk.) Subjects: | MESH: Forms and Records Control methods | Medical Records standards Classification: LCC R697.P45 (ebook) | LCC R697.P45 (print) | NLM W 80 | DDC 651.5/04261 dc23 LC 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 + $.25 00_Sullivan_FM.indd 7/5/18 5:15 PM 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! Copyright © 2019 by F A Davis Company All rights reserved 00_Sullivan_FM.indd iii 7/5/18 5:15 PM 00_Sullivan_FM.indd 7/5/18 5:15 PM Reviewers Gilbert Boissonneault, PhD, PA-C, DFAAPA Professor Division of Physician Assistant Studies Medical University of South Carolina Charleston, SC Elizabeth Brownlee, MPAS, PA-C Physician Assistant, Assistant Professor School of Physician Assistant Studies, College of Medicine University of Florida Gainesville, FL Rhonda Glen Feldman, MHS, MSS, PA-C Program Director Physician Assistant University of New England Portland, ME Pat Kenney-Moore, EdD, PA-C Associate Director/Academic Coordinator/Associate Professor School of Medicine, Division of Physician Assistant Education Oregon Health & Science University Portland, OR Copyright © 2019 by F A Davis Company All rights reserved 00_Sullivan_FM.indd Sara Haddow Liebel, MSA, PA-C Education Director/Associate Professor Physician Assistant Department, College of Allied Health Sciences Augusta University Augusta, GA Nicole Schmitz, DNP, APRN, PNP, CHSE Assistant Professor Nursing Minnesota State University – Mankato Mankato, MN Emily K Sheff, CMSRN, FNP, BC Assistant Professor School of Nursing MGH Institute of Health Professions Boston, MA v 7/5/18 5:15 PM 00_Sullivan_FM.indd 7/5/18 5:15 PM 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 prenatal chapter Larissa J. Bech, MSN, RN, FNP-C contributed the pediatric records Without their contributions, the prenatal and p ediatric visit notes would not exist They Copyright © 2019 by F A Davis Company All rights reserved 00_Sullivan_FM.indd bring real-world knowledge and hands-on patient care experience where I would only have been able to read and write about what others 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 P ublishing; and Robert Butler, Production Manager There’s probably not another publishing company 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 vii 7/5/18 5:15 PM 00_Sullivan_FM.indd 7/5/18 5:15 PM Brief Contents Part 1: Foundations of Documentation Chapter 1 Medicolegal Principles of Documentation Chapter 2 The Comprehensive History and Physical Examination 23 Chapter 3 SOAP Notes 45 Part II: Documentation Related to Outpatient Care Chapter 4 Documenting Prenatal Care and Perinatal Events 79 Chapter 5 Pediatric Preventive Care Visits 93 Chapter 6 Adult Preventive Care Visits 125 Chapter 7 Older Adult Preventive Care Visits 153 Chapter 8 Outpatient Charting and Communication 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 from the Hospital 285 Appendix A Document Library 309 Appendix B A Guide to Sexual History Taking 373 Appendix C I SMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations 375 Appendices Bibliography 377 Index 387 Copyright © 2019 by F A Davis Company All rights reserved 00_Sullivan_FM.indd ix 7/5/18 5:15 PM Bibliography | 379 families https://brightfutures.aap.org/Pages/default.aspx Accessed June 10, 2017 American Academy of Pediatrics Documenting parental refusal to have their children vaccinated https://www.aap.org/en-us/ Documents/immunization_refusaltovaccinate.pdf Accessed June 8, 2017 American Academy of Pediatrics Pediatric visit documentation forms package https://shop.aap.org/pediatric-documentationforms-economy-package Accessed June 6, 2017 Bayley N Bayley scales of infant and toddler development 3rd ed Pearson website http://www.pearsonassessments com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid= 015-8027-23X&Mode=summary Accessed January 21, 2010 Bernstein DP, Fink L, Handelsman L, Foote J Initial reliability and validity of a new retrospective measure of child abuse and neglect Am J Psychiatry 1994;151(8):1132‒1136 Briere J Child Abuse Trauma: Theory and Treatment of the Lasting Effects Newbury Park, CA: Sage Publications; 1992 http:// www.johnbriere.com/cmis.htm Accessed January 31, 2010 Centers for Disease Control and Prevention CDC growth charts http://www.cdc.gov/growthcharts/data/who/GrChrt_ Boys_24LW_100611.pdf Accessed June 1, 2017 Centers for Disease Control and Prevention E-cigarette use triples among middle and high school students in just one year https://www.cdc.gov/media/releases/2015/p0416-e-cigaretteuse.html Updated April 2015 Accessed June 1, 2017 Centers for Disease Control and Prevention National health and nutrition examination survey http://www.cdc.gov/nchs/ nhanes/about_nhanes.htm Accessed May 25, 2017 Centers for Disease Control and Prevention Vaccine information statements https://www.cdc.gov/vaccines/hcp/vis/index.html Accessed June 1, 2017 Centers for Disease Control and Prevention Vaccine safety http://www.cdc.gov/vaccinesafety/ensuringsafety/history/ index.html Accessed June 1, 2017 Centers for Medicare and Medicaid Services Early and periodic screening, diagnostic, and treatment https://www.medicaid gov/medicaid/benefits/epsdt/index.html Accessed June 6, 2017 Child Welfare Information Gateway What is child abuse and neglect? 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Hippokratia 2007;11(1):13‒21 Chapter American Medical Association Guidelines for physicianpatient electronic communications https://policysearch.ama-assn.org/policyfinder/detail/Policy%20 H-478.997?uri=%2FAMADoc%2FHOD.xml-0-4344.xml Updated January 2017 Accessed October 1, 2017 American Medical Informatics Association Guidelines for the clinical use of electronic mail with patients https:// www.researchgate.net/publication/238654517_Guidelines_ for_the_Clinical_Use_of_Electronic_Mail_with_Patients Published 2012 Accessed October 1, 2017 Bhargava R How doctors are using social media http://blog ogilvypr.com/2009/09/how-doctors-are-using-social-media Published September 22, 2009 Accessed March 5, 2010 Brooks RG, Menachemi N Physicians’ use of email with patients: factors influencing electronic communication and adherence to best practices J Med Internet Res 2006;8(1):e2 http://www.jmir.org/2006/1/e2 Accessed October 1, 2017 California Health Care Foundation New guidelines help physicians choose among online patient communication options http:// www.chcf.org/media/press-releases/2003/new-guidelineshelp-physicians-choose-among-online-patient-communicationoptions Published November 17, 2003 Accessed March 29, 2010 Centers for Medicare and Medicaid Services Telehealth Services https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNProducts/ Downloads/Telehealth-Services-Text-Only.pdf Accessed March 25, 2017 Chretien KC, Greysen SR, Chretien JP, Kind T Online posting of unprofessional content by medical students JAMA 2009;302(12):1309‒1315 http://jama.ama-assn.org/cgi/ reprint/302/12/1309 Accessed April 2, 2010 Crotty BH, Tamrat Y, Mastaghimi A, Safran C, Landon BE Patient-to-physician messaging: volume nearly tripled as more patients joined system, but per capita rate plateaued Health Aff 2014;33:1817-1822 Darves B Social media and physicians http://www.nejmjobs.org/ career-resources/social-media-and-physicians.aspx Published March 2010 Accessed April 3, 2010 Delbanco T, Walker J, Bell SK, et al Inviting patients to read their doctors’ notes: a quasi-experimental study and a look ahead Ann Intern Med 2012;157:461‒470 Dolan PL Social networking etiquette: making virtual acquaintances http://www.ama-assn.org/amednews/2008/ 06/02/bisa0602.htm Published June 2, 2008 Accessed April 6, 2010 Farnan JM, Snyder Sulmasy L, Worster BK, et al Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards Ann Intern Med 2013;158:620‒627 Fox S, Duggan M Mobile health 2012 http://www.pewinternet org/-/media//Files/Reports/2012/PIP_MobileHealth2012_ FINAL.pdf Accessed March 31, 2017 Fox S, Jones S The social life of health information http://www pewinternet.org/-/media//Files/Reports/2009/PIP_Health_ 2009.pdf Accessed March 30, 2017 Gandolf S Nearly all US hospitals use social media: now what? http://www.healthcaresuccess.com/blog/hospital-marketing/ nearly-us-hospitals-use-social-media-now.html Updated December 2014 Accessed October 1, 2017 Guadagnino C Physician websites evolve Physician’s News Digest January 2008 http://www.physiciansnews.com/cover/108 html Accessed October 1, 2017 Gulick SL Social media: a brave new world for doctors J Am Coll Radiol 2011;8:366‒368 Hennessy M How social media can make physicians better doctors http://www.hcplive.com/primary-care/publications/ mdng-primarycare/2009/Oct2009/EdNote Published September 28, 2009 Accessed March 31, 2010 Jain SH Practicing medicine in the age of Facebook N Engl J Med 2009;361:7 Accessed March 3, 2010 Copyright © 2019 by F A Davis Company All rights reserved 16_Sullivan_Bib.indd 381 7/3/18 7:33 PM 382 | Bibliography Joseph A, Stuhan C The reimbursement outlook for virtual visits https://www.advisory.com/research/medicalgroup-strategy-council/practice-notes/2015/february/ virtual-visits Published February 18, 2015 Accessed October 6, 2017 Kinsey MJ Please hold for the doctor: why you still can’t email your physicians with a simple question http://www.slate.com/ articles/technology/future_tense/2014/06/telemedicine_ e_visits_doctors_should_start_using_email.html Accessed October 1, 2017 Larson J The new world of physician-patient electronic communication AMN Healthcare, Inc website https://www amnhealthcare.com/latest-healthcare-news/the-new-worldphysician%E2%80%93patient-electronic-communication Accessed October 1, 2017 Lee JL, Choudhry N, Wu AW, et al Patient use of email, Facebook, and physician websites to communicate with physicians: a national online survey of retail pharmacy users J Gen Intern Med 2016;31:45‒51 Lowes R Patient-centered care for better patient adherence http://www.aafp.org/fpm/980300fm/patient.html Accessed October 1, 2017 MAG Mutual Insurance Company Telephone encounters and triage https://www.magmutual.com/learning/article/ risk-management-guidelines-telephone-encounters Accessed October 1, 2017 Malamon W Integrating patient email into your practice https:// www.tmlt.org/tmlt/tmlt-resources/newscenter/blog/2010/ Integrating-patient-email-into-your-practice.html Accessed October 1, 2017 Menachemi N, Prickett CT, Brooks RG The use of physicianpatient email: a follow-up examination of adoption and best-practice adherence 2005-2008 J Med Internet Res 2011;13:e23 Moawad H Controlling your online presence http://www mdmag.com/physicians-money-digest/contributor/heidimoawad-md/2016/12/controlling-your-online-presence Accessed March 28, 2017 Moawad H Physician social media 101 http://www.mdmag com/physicians-money-digest/contributor/heidi-moawadmd/2016/11/physician-social-media-101 Accessed March 28, 2017 Neuner J, Fedders M, Caravella M, Bradford L, Schapira M Meaningful use and the patient portal: patient enrollment, use and satisfaction with patient portals at a later-adopting center Am J Med Qual 2014;30:105‒113 Office of the Information & Privacy Commissioner for British Columbia http://www.oipc.bc.ca/pdfs/Physician_Privacy_ Toolkit/UseofEmailbyPhysicians.pdf Last updated June 25, 2009 Accessed March 28, 2010 Pho K Useful Twitter advice for doctors http://www.kevinmd com/blog/2010/01/twitter-advice-doctors.html Published January 7, 2010 Accessed October 1, 2017 Princeton Insurance Reducing risk: telephone communication http://www.princetoninsurance.com/downloads/reducing_ risk/Tips.to.reduce.phone.liability.May05.pdf Accessed October 1, 2017 Quatre T Email: the new frontier in physician-patient communication? The Healthcare Entrepreneur Blog http:// vantageclinicalsolutions.com/2008/04/23/email-the-newfrontier-in-physician-patient-communication/ Accessed October 1, 2017 Rajecki R Patients see benefits of email and web communications—if free Published October 29, 2009 http://www.modernmedicine.com/modernmedicine/article/ articleDetail.jsp?id=636485 Accessed March 29, 2010 Rosen P, Kwoh CK Patient-physician email: an opportunity to transform pediatric health care delivery Pediatrics 2007;120(4):701‒706 Schwimmer J What are the benefits and advantages of telemedicine? https://www.healthline.com/health/telemedicinebenefits-and-advantages#1 Published August 1, 2015 Accessed July 1, 2017 Shafrin J Physician-patient email communication: a review http://healthcare-economist.com/2006/08/02/physicianpatient-email-communication-a-review Published August 2, 2006 Accessed October 1, 2017 Torrey T Phone and online service codes on your medical bill: if you find these codes on your bill, you’ll know what they are https://www.verywell.com/cpt-and-hcpcs-codes-for-telephonecalls-and-emails-2615304 Updated March 19, 2017 Accessed October 7, 2017 Versel N Doctors and social media: benefits and dangers Medscape website http://www.medscape.com/viewarticle/711717 November 9, 2009 Accessed April 2, 2010 White CB, Moyer CA, Stern DT, Katz SJ A content analysis of e-mail communication between patients and their providers: Patients get the message J Am Med Inform Assoc 2004;11:260‒267 http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC436072 Accessed April 3, 2010 Wike K 93% of patients prefer doctors who email Health IT Outcomes https://www.healthitoutcomes.com/doc/ofpatients-prefer-doctors-who-email-0001 June 9, 2014 Accessed April 14, 2018 Wynn P Brave new world of social media http://www.amsa org/AMSA/Homepage/Publications/TheNewPhysician/ 2010/0110SocialMedia.aspx Published February 2010 Accessed April 8, 2010 Yaraghi N The doctor won’t text you now: why doctor-patient communication is still stuck in the 20th century https://www usnews.com/opinion/blogs/policy-dose/2015/11/05/ why-doctors-still-dont-use-text-or-email-with-patients Accessed March 30, 2017 Zhou YY, Garrido T, Chin HL, Wiesenthal AM, Liang LL Patient access to electronic health records with secure messaging: impact on primary care utilization Am J Manag Care 2007;13:418‒424 Chapter Abramson EL, Bates DS, Jenter C, et al Ambulatory prescribing errors among community-based providers in two states J Am Med Inform Assoc 2012;19:644‒648 Centers for Medicare and Medicaid Services http://www.cms gov/MMAUpdate Accessed February 1, 2010 Davis R Prescription writing and the PDR http://www sh.lsuhsc.edu/fammed/OutpatientManual/PrescripWritingPDR.htm Accessed October 1, 2017 Donyai P, O’Grady K, Jacklin A, Barber N, Franklin BD The effects of electronic prescribing on the quality of prescribing Br J Clin Pharmacol 2007;65(2):230‒237 Families USA Congress delivers help to people with Medicare: an overview of the Medicare Improvements for Patients and Providers Act of 2008 http://www.familiesusa.org/assets/ pdfs/medicare-improvements-act-2008.pdf Accessed January 25, 2010 Food and Drug Administration Medication errors http://www fda.gov/Drugs/DrugSafety/MedicationErrors/default.htm Updated April 2017 Accessed October 1, 2017 Gabriel MH, Swain M E-Prescribing Trends in the United States ONC data brief, no.18 Washington, DC: Office of the National Coordinator for Health Information Technology; July 2014 Copyright © 2019 by F A Davis Company All rights reserved 16_Sullivan_Bib.indd 382 7/3/18 7:33 PM Bibliography | 383 Hale PL Electronic Prescribing for the Medical Practice: Everything You Wanted to Know but Were Afraid to Ask Chicago, IL: Healthcare Information Management and Systems Society; 2007 IMS Health IMS health reports U.S prescription sales grew 5.1 percent in 2009, to $300.3 billion http://www.imshealth com/portal/site/imshealth/menuitem.a46c6d4df3db4b3d88f611019418c22a/?vgnextoid=d690a27e9d5b7210VgnVCM10 0000ed152ca2RCRD&cpsextcurrchannel=1 Updated April 1, 2010 Accessed June 13, 2010 Institute of Medicine Preventing medication errors Report brief http://www.iom.edu/~/media/Files/Report%20Files/2006/ Preventing-Medication-Errors-Quality-Chasm-Series/ medicationerrorsnew.ashx Published July 2006 Accessed December 17, 2010 Isaac T, Weissman JS, Davis RB, et al Overrides of medication alerts in ambulatory care Arch Intern Med 2009;169(3):305-311 Johnston D, Pan E, Walker J, Bates DW, Middleton B Patient Safety in the Physician’s Office: Assessing the Value of Ambulatory CPOE The Center for Information Technology Leadership; Boston, MA; 2004 Kaushal R, Kern LM, Barron Y, Quaresimo J, Abramson EL Electronic prescribing improves medication safety in community-based office practices J Gen Intern Med 2010;25:530‒536 Medicare.gov Prescription drug coverage: basic information http://www.medicare.gov/pdp-basic-information.asp Accessed January 12, 2010 National Coordinating Council for Medication Error Reporting and Prevention Council recommendations to enhance accuracy of prescription writing http://www.nccmerp.org/council/ council1996-09-04.html Accessed February 8, 2010 National ePrescribing Patient Safety Initiative The time for ePrescribing is now Allscripts website http://www.allscripts.com/ brochures/EP1_NEPSI_CSv1_10508.pdf Accessed January 30, 2010 National Health Statistics Reports, Number National ambulatory medical care survey 2006 summary Centers for Disease Control and Prevention website http://www.cdc.gov/nchs/ data/nhsr/nhsr003.pdf Published August 6, 2008 Accessed September 10, 2009 National Institute of Health Policy The Medicare Moderniza tion Act of 2003 http://www.nihp.org/Reports/ NIHPMMA2003Whitepaper.pdf Accessed January 20, 2010 National Progress Report on E-prescribing; Surescripts website http://www.surescripts.com/downloads/NPR/nationalprogress-report.pdf Published December 2007 Accessed November 30, 2009 OmniMD Eprescribing http://www.omnimd.com/html/ prescription.html Accessed November 14, 2009 OpenClinical E-prescribing http://www.openclinical.org/ e-prescribing.html Last updated August 31, 2005 Accessed October 13, 2009 PharmacyTimes The state of controlled substance e-prescribing http://www.pharmacytimes.com/news/the-state-ofe-prescribing-of-controlled-substances Accessed October 1, 2017 Statista Total number of medical prescriptions dispensed in the US from 2009 to 2016 (in millions) https://www.statista com/statistics/238702/us-total-medical-prescriptions-issued Accessed October 1, 2017 US Department of Justice Drug Enforcement Agency Controlled substances schedules https://www.deadiversion.usdoj gov/21cfr/21usc/812.htm Accessed October 1, 2017 US Department of Justice Drug Enforcement Agency Electronic prescriptions of controlled substances https://www deadiversion.usdoj.gov/ecomm/e_rx/faq/faq.htm Accessed October 1, 2017 US Department of Justice Drug Enforcement Agency Practitioner’s manual https://www.deadiversion.usdoj.gov/pubs/ manuals/pract Accessed October 1, 2017 US Food and Drug Administration Title 21 Code of Federal Regulations http://www.accessdata.fda.gov/scripts/cdrh/ cfdocs/cfcfr/cfrsearch.cfm Accessed December 20, 2009 Chapter 10 American Hospital Association AHA hospital statistics: fast facts on US hospitals http://www.aha.org/research/rc/ stat-studies/fast-facts.shtml Updated January 2017 Accessed October 1, 2017 Bobb A, Gleason K, Husch M, Geinglass J, Yarnold PR, Noskin GA The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry Arch Intern Med 2004;164:785‒791 California Health Care Foundation Computerized physician order entry (CPOE) is succeeding in community hospitals http://www.chcf.org/media/press-releases/2003/computerizedphysician-order-entry-cpoe-is-succeeding-in-communityhospitals Accessed October 1, 2017 Cartmill RS, Walker JM, Blosky MA, et al Impact of electronic order management on the timeliness of antibiotic administration in critical care patients. Int J Med Inform 2012;81(11):782‒791 Centers for Disease Control and Prevention 2006 national hospital discharge survey National health statistics reports; No Published July 2008 http://www.cdc.gov/nchs/data/ nhsr/nhsr005.pdf Accessed September 4, 2009 Centers for Medicare and Medicaid Services Title 42-Public Health; Chapter 4, Section 482.24 https://www.cms.gov/ Regulations-and-Guidance/Guidance/Manuals/downloads/ som107ap_a_hospitals.pdf Accessed October 1, 2017 Charles K, Cannon M, Hall R, Coustasse A Can utilizing a computerized provider order entry (CPOE) system prevent hospital medical errors and adverse drug events? Perspect Health Inf Manag 2014;11(Fall) Classen DC, Avery AJ, Bates DW Evaluation and certification of computerized provider order entry systems J Am Inform Assoc 2007;14(1):48‒55 Cornish PL, Knowles SR, Marchesano R, et al Unintended medication discrepancies at the time of hospital admission Arch Intern Med 2005;65(4):424‒429 Devine EB, Williams EC, Martin DP, et al Prescriber and staff perceptions of an electronic prescribing system in primary care: a qualitative assessment. BMC Med Inform Decis Mak 2010;10(72):72‒83 Dixon BE, Zafar A Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health IT Portfolio (Prepared by the AHRQ National Resource Center for Health IT) AHRQ publication 09-0031-EF Rockville, MD: Agency for Healthcare Research and Quality Published January 2009 Accessed October 1, 2017 Greenwald JL, Halasyamani L, Greene J, et al Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps J Hosp Med 2010;5:477‒485 Institute for Safe Medication Practices List of error-prone abbreviations, symbols, and dose designations http://www ismp.org/tools/errorproneabbreviations.pdf Accessed October 1, 2017 Kaushal R, Shojania KG, Bates DW Effects of computerized physician order entry and clinical decision support systems Copyright © 2019 by F A Davis Company All rights reserved 16_Sullivan_Bib.indd 383 7/3/18 7:33 PM 384 | Bibliography on medication safety: a systematic review Arch Intern Med 2003;163:1409‒1416 Kohn LT, Corrigan JM, Donaldson MS, eds Institute of Medicine Report To Err Is Human: Building a Safer Health System Washington, DC: National Academy Press; 2000 Magid S, Forrer C, Shaha S Duplicate orders: an unintended consequence of computerized provider/physician order entry (CPOE) implementation: analysis and mitigation strategies Appl Clin Inform 2012;4:377‒391 Mattison ML, Afonso KA, Ngo LH, Mukamal KJ Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system. Arch Intern Med 2010;170(15):1331‒1336 OpenClinical Computer physician order entry systems http:// www.openclinical.org/cpoe.html Updated June 5, 2006 Accessed October 1, 2017 Osheroff JA, Pifer EA, Teich JM, Sitting DF, Jenders RA Improving Outcomes with Clinical Decision Supports: An Implementer’s Guide Chicago, IL: Health Information and Management Systems Society; 2005 Osheroff JA, Pifer EA, Teich JM, Sittig DF, Jenders RA Improving Outcomes with Clinical Decision Supports: An Implementer’s Guide 2nd ed Chicago, IL: Health Information and Management Systems Society; 2012 The Leapfrog Group Medication safety: data by hospital on nationally standardized metrics http://www.leapfroggroup org/sites/default/files/Files/Castlight%20Leapfrog%20Medication%20Safety%20Report%202017_Final.pdf Accessed October 3, 2017 US Department of Justice Americans with Disabilities Act, Title II http://www.ada.gov/t2hlt95.htm Accessed October 1, 2017 Zimlichman EC, Keohane C, Franz WL, et al Return on investment for vendor computerized physician order entry in four community hospitals: the importance of decision support. Jt Comm J Qual Patient Saf/Joint Commission Resources. 2013;39(7):312‒318 Chapter 11 Centers for Medicare and Medicaid Services Electronic health records provider fact sheet https://www.cms.gov/ Medicare-Medicaid-Coordination/Fraud-Prevention/ Medicaid-Integrity-Education/Downloads/docmattersehr-providerfactsheet.pdf Accessed October 1, 2017 Cueva JP EMR cloning: a bad habit Chicago Medical Society website http://www.cmsdocs.org/news/emr-cloning-a-badhabit Accessed October 1, 2017 ECRI Institute Copy/paste: prevalence, problems, and best practices https://www.ecri.org/Resources/HIT/CP_Toolkit/ CopyPaste_Literature_final.pdf Published October 2015 Accessed October 1, 2017 Gomella LG, Haist SA Clinician’s Pocket Reference 11th ed San Francisco, CA: McGraw-Hill; 2006 Murray B Informed consent: what must a physician disclose to a patient? Virtual Mentor 2012;14:563-566 Samaritan GA Standard of care deviation results in patient’s death Copy & paste documentation not helpful to the defense J Med Assoc Ga 2010;99(2):32‒33 The Joint Commission Preventing copy-and-paste errors in EHRs https://www.jointcommission.org/assets/1/23/Quick_ Safety_Issue_10.pdf Published February 2015 Accessed October 1, 2017 University of Florida Medical School Writing an effective daily progress note http://clerkship.medicine.ufl.edu/ jacksonville/documenting-in-the-medical-record/writing-an-effective-daily-progress-note Accessed October 1, 2017 Chapter 12 Agency for Healthcare Research and Quality Strategy 4: care transitions from hospital to home: IDEAL discharge planning https://www.ahrq.gov/sites/default/files/wysiwyg/ professionals/systems/hospital/engagingfamilies/strategy4/ Strat4_Tool_1_IDEAL_chklst_508.pdf Updated June 2013 Accessed October 1, 2017 Allaudeen N, Vidyarthia A, Maselli J, Auerbach A Redefining readmission risk factors for general medicine patients J Hosp Med 2011;6:54-60 American Society of Anesthesiologists Practice guideline for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists task force on acute pain management Anesthesiology 2004;100:1573‒1581 http://www.asahq.org/publications AndServices/pain.pdf Accessed May 8, 2009 Centers for Disease Control and Prevention National hospital discharge survey: 2007 summary National Health Statistics Report 29 October 26, 2010 Accessed October 1, 2017 Cohen MR, Weber RJ, Moss J Institute of Safe Medication Practices Patient-controlled analgesia: making it safer for patients Institute of Safe Medication Practices website http://www.ismp.org/profdevelopment/PCAMonograph.pdf Published 2006 Accessed June 1, 2009 Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ Leaving against medical advice: risk of 30-day mortality and hospital readmission J Gen Intern Med 2010;25(9):926‒929 Graham KL, Wilker EH, Howell MD, Davis RB, Marcantonio ER Differences between early and late readmissions among patients: a cohort study Ann Intern Med 2015;162:741‒749 Grass JA Patient-controlled analgesia Anesth Analg 2005;101:S44‒61 Greenwald J Improving hospital discharge Physician’s News Digest https://physiciansnews.com/2008/11/22/improving-hospital-discharge/ Published November 2008 Accessed October 1, 2017 Hertz BT Act quickly and listen a lot: what to when a patient wants to leave AMA ACP Hospitalist http://www acphospitalist.org/archives/2010/03/against.htm Accessed October 1, 2017 Hwang SW, Li J, Gupta R, Chien V, Martin RE What happens to patients who leave hospital against medical advice? CMAJ 2003;168(4):417‒420 Improving Hospital Discharge Through Medication Reconciliation and Education Agency for Healthcare Research and Quality website https://www.ahrq.gov/professionals/ quality-patient-safety/patient-safety-resources/resources/ discharge/index.html Updated October 2012 Accessed October 1, 2017 Koo PJS Balancing postoperative analgesia and management of side effects Medscape website http://cme.medscape.com/ viewarticle/429661_2 Accessed May 22, 2009 Kruse RL, Hays HD, Madsen RW, Emons MF, Wakefield DS, Mehr DR Risk factors for all-cause hospital readmission within 30 days of hospital discharge J Clin Outcomes Manag 2013;20:203‒214 National Patient Safety Foundation Partnership for clear health communication at the National Patient Safety Foundation http://www.npsf.org/pchc Accessed April 28, 2009 Copyright © 2019 by F A Davis Company All rights reserved 16_Sullivan_Bib.indd 384 7/3/18 7:33 PM Bibliography | 385 Stranges E, Wier L, Merrill CT, Steiner C Hospitalizations in which patients leave the hospital against medical advice, 2007 Hospital Cost and Utilization Project Statistical Brief #78 Agency for Healthcare Research and Quality https://www hcup-us.ahrq.gov/reports/statbriefs/sb78.jsp Published 2009 Accessed October 1, 2017 The Virtual Anesthesia Textbook Post-operative Pain http://www virtual-anaesthesia-textbook.com/vat/pain.html Updated April 20, 2009 Accessed May 30, 2009 US Pharmacopeia Quality review: patient-controlled analgesia pumps http://www.usp.org/pdf/EN/patientSafety/ qr812004-09-01.pdf Accessed June 2, 2009 Weiss BD Health Literacy and Patient Safety: Help Patients Understand 2nd ed Chicago, IL: American Medical Association; 2007 Copyright © 2019 by F A Davis Company All rights reserved 16_Sullivan_Bib.indd 385 7/3/18 7:33 PM 16_Sullivan_Bib.indd 386 7/3/18 7:33 PM Index A Abbreviations common prescription abbreviations, 203 dangerous abbreviations to avoid, 204 Error-Prone Abbreviations, Symbols and Dose Designations, Appendix C errors, 195, 199, 201 prescription writing, 203 Abdomen, examination of, 30 Abdominal aortic aneurysm screening, 138 Abducens nerve, 30 Abortus, defined, 80 Abuse, child, 102, 105 Acoustic nerve, 30 Activities of daily living, 156 Activity admission orders, 227 level, in discharge order, 286 perioperative orders, 230 AD CAVA DIMPLS mnemonic, 225–226, 230 Admission orders, 223, 225–229 Admit notes, 237 Admitting patient to hospital admission history and physical examination, 218–221 admission orders, 223, 225–229 overview of, 217 surgical history and physical examination, 221–223, 260, 261–263 Adolescents, 102 Advance directives, 165 Adverse drug events electronic prescribing, 203 hospitalized patients, 228, 234 medications, 201 Against medical advice, patient leaving hospital, 291, 293 Agency for Healthcare Research and Quality (AHRQ), 137 Ages and Stages Questionnaires (ASQ-3), 99 Age-specific physical examinations, 106, 107–108 Alcohol consumption, 130–131 Alcoholism, 131 Alcohol Use Disorders Identification Test (AUDIT), 131, 132 Allergic/immunologic system, review of, 29 Allergies admission orders, 228 comprehensive history and physical examination, 25–26 drug, 25 in medication list, 176 perioperative orders, 230 Ambulatory medical care, 125 American Academy of Pediatrics (AAP), 94 American College of Physicians (ACP), 186–187 American Health Information Management Association (AHIMA), 186 American Medical Association, 5, 186 American Recovery and Reinvestment Act, Americans with Disabilities Act, 219 Anorexia nervosa, 106 Anticipatory guidance, 100–102 Anti-emetics, 232 Apgar scoring, 86, 87 ASQ-3 (Ages and Stages Questionnaires), 99 Assessments in admission history and physical examination, 220 Assessment portion of SOAP notes, 52–54, 257 balance and mobility, 162 BRCA risk assessment and genetic counseling/testing, 137 cardiopulmonary, 163 cardiovascular disease, 138 cognitive, 162 comprehensive history and physical examination, 32 general, 48, 220 geriatric risk factors, 153–162 medical admissions, 258 Mini Nutritional Assessment—Short Form (MNA-SF), 156, 159 risk factor assessment through history taking, 153–160 risk factor assessment through physical examination, 160–162 sexually transmitted infections, 137, 138 in surgical history and physical examination, 223 Copyright © 2019 by F A Davis Company All rights reserved 17_Sullivan_Index.indd 387 Tinetti Performance Oriented Mobility Assessment tool, 162 Asthma, genetic tendency, 135 Asymmetrical tonic neck reflex, 108 Attending physician, 289 AUDIT (Alcohol Use Disorders Identification Test), 131, 132 Authorization, to disclose health information, 11 B Balance assessment, 162 Bayley Scales of Infant and Toddler Development (Bayley-III), 99 Beers criteria, 155 Berg Balance Test, 162 Billing information, 179 Bishop score, 81–82 Blood product transfusions, 134 BMI See Body mass index (BMI) Body mass index (BMI) pediatric screenings, 94, 97–98 risk-factor identification using, 128–129 BRCA risk assessment and genetic counseling/testing, 137 Breast cancer screening, 137 examination of, 30 genetic tendency for cancer, 135 Bright Futures program, 93–94, 99 C CAGE questionnaire, 130–131 Cancer breast, 135, 137 cervical, 137 colon, 137 colorectal, 135 genetic tendency, 135 oral, 134 ovarian, 135 screening mammography, 126 CAPTA (Child Abuse Prevention and Treatment Act), 102 Cardiopulmonary assessment, preoperative evaluation of older adults, 163 387 7/6/18 1:36 PM 388 | Index Cardiovascular system examination, 30 genetic tendency for disease, 135 review of, 28, 107 risk assessment for disease, 138 Catheter care, 233 CDC See Centers for Disease Control and Prevention (CDC) CDSS (Clinical Decision Support System), 205–206, 235 CDT (clock-drawing test), 162 Centers for Disease Control and Prevention (CDC) body mass index, 94 growth standards, 94 medical records content for hospitalized patients, 217 older adult vaccinations, 162 oral health, 134 vaccinations, 100 Centers for Medicare and Medicaid Services (CMS) admission history and physical examination, 218 comprehensive history and physical examination, 24 documentation guidelines, electronic prescribing, 204 EMR note review, 260 prescription writing, 197 telemedicine, 186 Cerebellum, 30 Cervical cancer screening, 137 Cervix score, 81–82 Chief complaint, 24–25, 218, 221 Child abuse, 102, 105 Child Abuse Prevention and Treatment Act (CAPTA), 102 Childhood Maltreatment Interview Schedule—Short Form (CMIS-SF), 105–106 Childhood obesity, 97 Childhood Trauma Questionnaire, 105 Chronic condition, Cigarette smoking, 129–130 Civil Rights Act of 1964, 219 Clear liquid diet, 232 Clinical Decision Support System (CDSS), 205–206, 235 Clock-drawing test (CDT), 162 CMS See Centers for Medicare and Medicaid Services (CMS) Coagulation studies, 179 Code of Federal Regulations (CFR), medical records content for hospitalized patients (42 CFR 482.24), 217 Codes See Current Procedural Terminology codes Cognitive assessment, 162 Colon cancer screening, 137 Colorectal cancer, genetic, 135 Communication with patient, 183–187 See also Outpatient charting and communication Comorbid conditions, 220 Comprehensive history and physical examination assessments, 32 components of, 24 diagnostic studies, 32 differential diagnosis, 32 history See History laboratory studies, 32 physical examination, 29–31 plan of care, 32 problem list, 32 sample, 32–35 uses of, 23 Computer-based patient record, Computerized Physician Order Entry (CPOE), 235–237 Condition admission orders, 227 perioperative orders, 230 Confidentiality, social media, 188 Consent, to disclose health information, 11, 273 Consultation letter, 182, 184 Consultations, 54–55, 182 Consulting provider, 182 Consult note, 266–270 Container information section, of prescription, 201 Contraceptive counseling and methods, 137 Controlled substances closed distribution system, 196, 206 Controlled Substances Act (CSA), 196 description of, 199 e-prescribing, 206 prescription writing for, 201, 205 Coronary heart disease, 135 Counseling, health, 139 Covered entities, 11 CPOE (Computerized Physician Order Entry), 235–237 Cranial nerves, 30, 108 Cultural history, 27 Current Procedural Terminology codes description of, evaluation and management services, 5–6 fraud, minutes used for medical discussion, 184 D Daily catheter care, 233 Daily orders, 260, 264–266 Daily progress note content of, 257–260 description of, 257 medical admissions, 257–259 surgical admissions, 260, 261–263 Daily wound care, 233 DDST-II (Denver Developmental Screening Test II), 99 DEA See Drug Enforcement Agency (DEA) Deferral of examination, 139 Definitive diagnosis, 52–53 Delivery note, 83–86 Demographic information, 80, 179 Denver Developmental Screening Test II (DDST-II), 99 Department of Health and Human Services (HHS), 3, 5, 219 Depression, 160, 161 Developmental screening, 98–99 Diabetes mellitus genetic tendency, 135 screening, 137, 138 Type 2, 97–98 Diagnosis admission orders, 227 perioperative orders, 230 Diagnostic studies admission history and physical examination, 220 admission orders, 229 comprehensive history and physical examination, 32 postoperative, 233–234 pre-operative evaluation of older adults, 163 surgical history and physical examination, 223 Diagnostic tests definitive diagnosis, 52–53 prenatal care documentation, 82 screening, 126 SOAP note documentation of results of, 50, 54 Diet discharge order, 286 postoperative, 230, 232 risk factor identification, 126, 128 Diet order, 228, 230, 232 Differential diagnosis admission history and physical examination, 220 comprehensive history and physical examination, 32 SOAP notes, 52, 53 surgical history and physical examination, 223 Discharge orders, 285–288 Discharge summary admitting and discharge diagnosis, 288 attending physician, primary provider, and consulting physician, 289 condition at discharge, 291 dates of admission and discharge, 288 description of, 288, 289 disposition, 291 follow-up instructions, 291 history, 289–290 hospital course in, 290 instructions, 291 laboratory values, 289–290 medications, 291 physical examination findings, 289–290 procedures, 289 sample, 292–293 Disclosure, of health information, 11 Disease prevention CDC See Centers for Disease Control and Prevention (CDC) prenatal care documentation, 83 Copyright © 2019 by F A Davis Company All rights reserved 17_Sullivan_Index.indd 388 7/6/18 1:36 PM Index | 389 preventive care, 125 purpose of, 55 Disposition, in discharge order, 286 Documentation alterations, analyzing, 47–48 correcting, evolution of, 1–2 general principles, 3–5 importance of, legal considerations for, 2–3 medical considerations for, medical records, ICD guidelines, 173 outpatient charting and communication, 183–187 patient counseling, 28 patient education, 55 perinatal and postpartum care, 83–88 prenatal care, 80–83 preventive care visits, 126–139 proven diagnosis, 53 purposes of, Dose designations, Appendix C Downcoding, Drug Abuse Screening Test, 131, 133 Drug allergies, 25 Drug Enforcement Agency (DEA) controlled substances, 196, 199, 206 e-prescribing, 196 prescription drug abuse, 197, 199 Drug names abbreviations, 199 look-alike and sound-alike, 195 E Ear examination, 30 Early and Periodic Screening, Diagnosis, and Treatment program (EPSDT), 93 Ears, nose, and mouth/throat, review of, 28 Eating disorders, 106 E-cigarettes, 102 Education, Internet sources for, 187 EHR (electronic health record), Electronic health record (EHR), Electronic medical records (EMR) barriers to, 9, 206 benefits of, 8–9 definition of, diagnostic test findings included in, 179 e-mailing of, 186–187 health-care delivery functions of, interoperability of, meaningful use of, 9–10 system qualifications, 204–205 Electronic nicotine delivery systems (ENDS), 102 Electronic patient record (EPR), Electronic prescribing adverse drug event reductions using, 203 barriers to, 206 benefits of, 205–206 certification issues, 206 components of, 204 cost considerations, 206 definition of, 203 description of, 8–9 error rates, 195–196 errors associated with, 206 federal initiatives for, 204 growth of, 206 lack of standards for, 206 qualified, 204–205 safety benefits of, 204, 205 Electronic Prescriptions for Controlled Substances rule, 206 E-mail, 185–187 benefits of, 185 concerns of, 185–186 provisions for using, 186–187 Emotional abuse, 102, 105 EMR See Electronic medical records (EMR) Endocrine system, review of, 29 Environmental allergies, 25 EPR (electronic patient record), EPSDT (Early and Periodic Screening, Diagnosis, and Treatment) program, 93 Evaluation and management services, 5–6, 218 Exercise, 126 Eye examination, 29 Eyes, review of, 28 F Facial nerve, 30 Falls, 160 Family Healthware, 135 Family history in admission history and physical examination, 219 description of, 26 risk-factor identification based on, 135 in surgical history and physical examination, 221 Federation of State Medical Boards (FSMB), 186–187 Female genitourinary system, review of, 108 Fever, postoperative, 260 FIST screening, 102, 104 Five Ws, 260, 264 Flow sheets, 179, 180 Follow-up care, in discharge order, 287 Follow-up instructions, 56, 58 Food allergies, 25, 176 Food and Drug Administration (FDA), confusion concerning drug names, 195 Food diary, 128 Fraud, Full liquid diet, 232 Full operative report, 271 Functional impairment, 156 G Gait, 162 Galant’s reflex, 108 GAPS (Guidelines for Adolescent Preventive Services), 102 Gastrointestinal system, review of, 28, 107 Gender-specific screening, 136–139 General assessments, 48, 220 Generic substitution section, of prescription, 201 Genetic diseases, 99, 135 Genitalia, examination of, 30 Genitourinary system, review of, 28 Geriatric Depression Scale (GDS), 160, 161 Geriatric Health Questionnaire, 153, 154–155 Geriatric risk factors See also Older adult preventive care visits assessment of, 153–162 cognition, 162 depression, 160 functional impairment, 156 gait, 162 mobility, 162 nutrition, 156–159 sensory deficits, 159–160 Geriatric syndrome, 160 Glossopharyngeal nerve, 30 Growth charts, 94, 96–97 Growth screening, 94, 97–98 Guidelines for Adolescent Preventive Services (GAPS), 102 Gynecological examination, 30 H HDDA (Hearing-Dependent Daily Activities) Scale, 159–160 Head circumference, 94 Head examination, 29 Healthcare Information and Management Systems Society (HIMSS), Health-care power of attorney, 165 Health education and counseling, 139 Health Information Technology for Economic and Clinical Health Act (HITECH), 9–10 Health Insurance Portability and Accountability Act (HIPAA) authorization, 11 background, 10 consent, 11 covered entities, 11 description of, 10 electronic health-care transitions, 10 electronic PHI communications, 186 electronic protected health information provisions, 186 Health Insurance Portability provision of, 10 individual rights, 11–12 minors, 12 Notice of Privacy Practices, 12–13 patient rights, 11–12 penalties for violating, 13 privacy policy elements, 13 Privacy Rule, 10–13 privacy violations and penalties, 13 protected health information, 11, 13, 186 security safeguards, 13–14 summary of, 14 violation of, 13 Copyright © 2019 by F A Davis Company All rights reserved 17_Sullivan_Index.indd 389 7/6/18 1:36 PM 390 | Index Health literacy, 126 Health maintenance, 125, 219 Health promotion defined, 55 prenatal care documentation, 83 Health Resources and Services Administration (HRSA), 94 Hearing-Dependent Daily Activities (HDDA) Scale, 159–160 Hearing loss, 159, 161–162 HEEADSSS, 102–104 HEENT, 29–30, 107 Hematologic system, review of, 29 Hepatitis C screening, 137 HHS (Department of Health and Human Services), 3, 5, 219 HIPAA See Health Insurance Portability and Accountability Act (HIPAA) History admission history and physical examination, 218–221 chief complaint, 24–25 comprehensive See Comprehensive history and physical examination family history, 26, 135, 219 identification section of, 24 medical admission, 218–221 older adult risk factors, 153–160 past medical history, 25–26, 218–219, 221 review of systems, 28–29, 219–220 sexual, 132–133 social history, 26–27 surgical history and physical examination, 221–223 History of the present illness (HPI), 25, 218, 221 HITECH (Health Information Technology for Economic and Clinical Health Act), 9–10 HIV screening, 137 Hospice, 166 Hospital admitting patient to See Admitting patient to hospital adverse drug events in hospitalized patients, 228, 234 Code of Federal Regulations (CFR), medical records content for hospitalized patients (42 CFR 482.24), 217 hospital course in discharge summary, 290 The Joint Commission, medical records content for hospitalized patients, 216 medical records content for hospitalized patients, 217 patient elopement from, 293–294 patient leaving, against medical advice, 291, 293 Hospital course, 290 HPI (history of the present illness), 25, 218, 221 Hyperlipidemia, 135 Hypertension screening, 137 Hypoglossal nerve, 30 I ICD See International Classification of Diseases (ICD) ICD-10, Identification section, of history, 24 Immunizations See also vaccinations in admission history and physical examination, 219 in adults, 139 in children, 100 Immunologic system, review of, 29 Indication section, of prescription, 200 Inpatient care consult note, 266–270 daily orders, 260, 264–266 daily progress note, 257–260, 261–263 full operative note, 271 operative note, 271 procedure note, 272–273 Inscription section, of prescription, 199–200 Institute for Safe Medical Practice (ISMP), 234–235 Instrumental activities of daily living, 156 Insurance, hospice services, 166 Integumentary system, review of, 29 International Classification of Diseases (ICD) description of, evaluation and management services, 6–7 ICD-10, medical record documentation, 173 Internet for medical education, 187 Interoperability, of electronic medical records, Interpreter for H&P, 25 Interpretive services, 219 Interventions admission orders, 228 done during the visit, 50–51 not done, 226 perioperative orders, 232 Intimate partner violence (IPV), 133–134 Intravenous therapy, 228 IPV screening and counseling, 137 J The Joint Commission, medical records content for hospitalized patients, 217 K Katz Index, 156 L Laboratory data, prenatal care documentation, 82 Laboratory studies in admission history and physical examination, 220 in admission orders, 229 description of, 32 outpatient, 179 in pediatric preventive care visits, 99 postoperative, 233–234 pre-operative evaluation of older adults, 163 shorthand for documenting results of, 261–263 in surgical history and physical examination, 223 Laboratory tests, 54 Laterality, 48 Latex allergies, 25 Lawton IADL Scale, 156 Lead exposure screening, 99 Legal considerations, 2–3 Level of service, 5–6 Living will, 165 Lymphatic system, review of, 29 M Male genitourinary system, review of, 107 Malpractice documentation involving laterality, 48 lack of patient counseling on risks of negative health habits, 28 patient education documentation, 55 prenatal test result documentation, 82 professional liability for vaccinations, 100 Mammogram, 126, 137 Maternal and Child Health Bureau (MCHB), 94 Maternal history, prenatal care documentation, 80–81 Medicaid, 186 Medical admissions, 257–259 assessment, 258 objective, 258 plan, 259 subjective, 257–258 Medical billing and coding, 5–7, 179 Medical history description of, 127–128 pediatric, 94, 95 Medical records credibility uses of, dictating of, 83, 237, 271, 288 prior, 183 Medicare e-mail communications, 186 hospice services, 166 Medicare Improvements for Patients and Providers Act, 204 Medicare Modernization Act of 2003, 204 Medication history for hospital admission, 218 Medication list description of, 176 in past medical history, 25 sample, 177 Medications in admission order, 228–229 adverse events, 201 in discharge order, 286–287 list of See Medication list older adults, 153, 155 Copyright © 2019 by F A Davis Company All rights reserved 17_Sullivan_Index.indd 390 7/6/18 1:36 PM Index | 391 perioperative, 232 reconciliation, 228–229 symptomatic, 229 Medicolegal alert adverse medication events, 201 consent, 273 copy/paste notes, 259–260 deferred examination, 139 follow-up instructions, 288 fraud, health-care POA, 165 interpreter services, discrimination, 219 intervention not done, 266 laboratory tests during pregnancy, 82 lack of patient counseling on risks of negative health habits, 28 laterality, 48 medication list, 176 patient education documentation, 55 patient noncompliance, 182 proven diagnosis documentation, 53 vaccination refusal, 100 Men, screening for, 138–139 Mental status, examination of, 30 Mini-Cog test, 162 Mini Nutritional Assessment—Short Form (MNA-SF), 156, 159 Minors, 12 Mnemonics, 25, 26 Mobility assessment, 162 Moro reflex, 108 Motor strength testing, 30 Mouth, review of, 107 Mouth examination, 30 Muscle strength grading, 30 Musculoskeletal examination, 30, 109 Musculoskeletal system, review of, 29, 108 “My Family Health Portrait,” 135 N Narrative format, for documenting objective information, 47–48, 49 National Child Abuse Hotline, 106 National Childhood Vaccine Injury Act (NCVIA), 100 National ePrescribing Patient Safety Initiative, 206 National Health and Nutrition Examination Survey (NHANES), 97 National Institute of Drug Abuse Modified Alcohol, Smoking, and Substance Involvement Screening Test (NIDA Modified ASSIST), 131 Neck, review of, 107 Neck examination, 30 Neglect, 102, 105 Neurological examination, 30–31 Neurological reflexes, 106 Neurological system, review of, 29, 108 New Ballard score, 87 Newborn physical examination, 87, 88 NHANES (National Health and Nutrition Examination Survey), 97 NIDA Modified ASSIST, 131 Noncompliance with medical treatment, 179, 181–182 Noncontrolled substances description of, 199 prescription writing for, 199–201 Nonpharmacological treatment, 55 Nose examination, 30 Notice of Privacy Practices, 12–13 NPO, 232 Nutrition information, 27 Mini Nutritional Assessment—Short Form (MNA-SF), 156, 159 National Health and Nutrition Examination Survey (NHANES), 97 Nutritional Health Checklist, 157–158 Nutrition Checklist warning signs, 158 in older adults, 156–159 prenatal care documentation, 83 risk-factor identification, 126, 128 O Occupational history, 134 Occupational Safety and Health Administration (OSHA), 134 Oculomotor nerve, 30 Office for Civil Rights (OCR), 219 Older adult preventive care visits See also Geriatric risk factors advance directives, 165 balance and mobility assessment, 162 cognitive assessment, 162 functional impairment, 156 Geriatric Health Questionnaire, 153, 154–155 geriatric syndromes, 160 hospice and palliative care, 166 medication use, 153, 155 mental health screening, 160, 161 nutrition, 156–159 overview, 153 pre-operative evaluations, 162–164 risk factor assessment through history taking, 153–160 risk factor assessment through physical examination, 160–162 sensory deficit screening, 159–160 sensory examinations, 161–162 USPSTF screening recommendations, 162 Olfactory nerve, 30 Operative note, 271 Optic nerve, 30 Oral cancer, 134 Oral health, 134 Orders admission, 223, 225–229 Computerized Physician Order Entry (CPOE), 235–237 daily, 260, 264–266 diet, 228, 230, 232 discharge, 285–288 perioperative, 229–234 postanesthesia care unit, 229, 231 postoperative, 230, 234 preoperative, 229, 230 special instruction, 229, 234 OSHA (Occupational Safety and Health Administration), 134 Osteoporosis caused by eating disorders, 106 genetic tendency, 135 screening, 137 Outpatient charting and communication advance directives, 165 billing information, 179 demographic information, 179 documentation of communication, 183–187 flow sheets, 179, 180 medication list, 176–178 noncompliance with medical treatment, 179, 181–182 overview of, 173 patient portal, 187 prior medical records, 183 problem list, 173–176 referrals, 182, 183 Ovarian cancer, 135 Overweight, 97 P Palliative care, 166 Palmar grasp reflex, 108 Papanicolaou test, 137 Parachute reflex, 108 Parents’ Evaluation of Developmental Status (PEDS), 99 Past medical history (PMH), 25–26, 218–219, 221 Patient-controlled analgesia, 232, 233 Patient counseling on risks of negative health habits, 28 Patient identification section, of prescription, 199 Patient portal, 187 Patient(s) communication with, 183–187 education of, 55–56 media use by, 187–188 noncompliance with medical treatment, 179, 181–182 rights of, under HIPAA, 11–12 Pediatric preventive care visits age-specific physical examinations, 106, 107–108 anticipatory guidance, 100–102 body mass index, 98 components of, 94, 97–106 developmental screening, 98–99 growth screening, 94, 97–98 immunization status, 100 laboratory screening tests, 99 overview of, 93–94 risk factor identification, 102–106 sports preparticipation physical examination, 106 PEDS (Parents’ Evaluation of Developmental Status), 99 Percentiles, 97 Copyright © 2019 by F A Davis Company All rights reserved 17_Sullivan_Index.indd 391 7/6/18 1:36 PM 392 | Index Perinatal and postpartum care documentation, 83–88 delivery note, 83–86 newborn history and physical examination, 88 newborn physical examination, 87 postpartum note, 86–87 Perioperative orders, 229–234 Personal habits review of, 26–27 risk factors associated with, 126 Pharmacological treatment, 55 Phenylketonuria (PKU), 99 PHI (protected health information), 11, 13, 186 Physical abuse, 102, 105 Physical examination admission, 218–221 age-specific, 106, 107–108 comprehensive See Comprehensive history and physical examination description of, 29–31 hospitalization, 218–221 medical admission, 218–221 prenatal care documentation, 81–82 sports preparticipation, 106 surgical, 221–223 Placing and stepping reflex, 108 Plan of care admission history and physical examination, 220 comprehensive history and physical examination, 32 surgical history and physical examination, 223 Plantar grasp reflex, 108 Postanesthesia care unit order, 229, 231 Postoperative progress note, 260, 264 Postoperative orders, 234 Postpartum note, 86–87 Practitioner, defined, 196 Preconception care, 137–138 Preexisting condition, 10 Prenatal care documentation, 80–83 demographic information, 80 health promotion and disease prevention, 83 laboratory data and diagnostic tests, 82 maternal history, 80–81 nutrition, 83 physical examination, 81–82 psychosocial factors, 83 visits throughout pregnancy, 84 Pre-operative evaluation of older adults, 162–164 Pre-operative history, 289 Pre-operative orders, 229, 230 Prescribers identification of, 199 safeguards for, 197, 199 Prescription form, 202 Prescription(s) adverse drug events caused by, 203 drug abuse, 196 elements of, 199, 200 illicit use of, 196 statistics regarding, 195 Prescription writing abbreviations used in, 203 authority for, 196–197 controlled medications, 201, 203, 205, 206 errors in, 195, 202–203, 228 noncontrolled medications, 199–201 prevalence of, 195 Preventive care visits adult, 153 components of, 126 definition of, 125 documentation of, 126–139 gender-specific screening, 136–139 health education and counseling, 139 immunization status, 139 older adult, 153 overview of, 125–126 pediatric See Pediatric preventive care visits risk factor identification See Risk factor identification Primary care provider, 182 Primary code, Primary prevention, 125 Prior medical records, 183 Privacy, under HIPAA Privacy Rule, 10–13 violations and penalties associated with, 13 Problem list admission history and physical examination, 220 comprehensive history and physical examination, 32 outpatient charting and communication, 173–176 surgical history and physical examination, 223 Procedure note, 272–273 Progress note, daily content of, 257–260 description of, 257 medical admissions, 257–259 surgical admissions, 260, 261–263 Prostate-specific antigen (PSA) screening, 138 Protected health information (PHI), 11, 13, 186 Providers communication with patient, 183–187 DEA identifier number for, 197, 199 other, communication with, 182 prescription writing by See Prescription writing PSA (prostate-specific antigen) screening, 138 Psychiatric system, review of, 29 Psychosocial factors, prenatal care documentation, 83 Q Quotations, 47–48 R Recommended Uniform Screening Panel (RUSP), 99 Rectal examination, 30 Referral defined, 182 letter sample, 183 Referring provider, 182 Refill information section, of prescription, 200–201 Reflexes, 31, 108 Rehabilitation Act of 1973, 219 Religious beliefs, 27 Respiratory examination, 30 Respiratory system, review of, 28, 107 Review of systems (ROS) admitting patient to the hospital, 219–220 comprehensive history and physical examination, 28–29 surgical history and physical examination, 223 Rheumatoid arthritis, 128 Rinne test, 161–162 Risk factor identification alcohol consumption, 130–131 blood product transfusions, 134 body mass index, 128–129 description of, 126 diet, 126, 128 exercise, 126 family history, 135 intimate partner violence, 133–134 nutrition, 126, 128 occupational history, 134 oral health, 134 pediatric, 102–106 safety measures, 134 screening tests, 135–136 sexual history, 132–133 substance abuse, 131–132, 133 tobacco use, 129–130 Rooting reflex, 108 ROS See Review of systems (ROS) RUSP (Recommended Uniform Screening Panel), 99 S Safety measures, 134 Screening(s) abdominal aortic aneurysm, 138 breast cancer, 137 cervical cancer, 137 colon cancer, 137 Denver Developmental Screening Test II (DDST-II), 99 developmental, 98–99 diabetes mellitus, 137, 138 diagnostic, 126 Drug Abuse Screening Test, 131, 133 Early and Periodic Screening, Diagnosis, and Treatment program (EPSDT), 93 FIST screening, 102, 104 gender-specific, 136–139 growth, 94, 97–98 hearing impairment screening, 159 hepatitis C, 137 HIV, 137 hypertension, 137 Copyright © 2019 by F A Davis Company All rights reserved 17_Sullivan_Index.indd 392 7/6/18 1:36 PM Index | 393 indications for, 126 IPV screening and counseling, 137 laboratory tests, 126 lead exposure, 99 for men, 138–139 mental health screening, 160, 161 National Institute of Drug Abuse Modified Alcohol, Smoking, and Substance Involvement Screening Test (NIDA ASSIST), 131 older adult medical conditions, 162 osteoporosis, 137 pediatric BMI, 94, 97–98 pediatric laboratory tests, 99 prostate-specific antigen (PSA), 138 recommended types of, 136–139 Recommended Uniform Screening Panel (RUSP), 99 risk factor identification based on, 135–136 screening mammography, 126 sensory deficit screening, 159–160 sexually transmitted infections, 137, 138 tuberculosis, 137 USPSTF screening recommendations, 162 for women, 136–138 Youth at Risk Screening Questionnaire, 105 Secondary codes, Secondary prevention, 125 Security, 13–14 Sensitive protected health information, 11 Sensory deficits in older adults, 159–160 Sensory examinations, 161–162 Sensory testing, 31 Sexual abuse, 102, 105 Sexual history, 132–133 Sexually transmitted infection (STI) adult preventive care, 133 email confidentiality, 186 genitourinary review of systems, 28 prenatal care documentation, 81 prenatal test result documentation, 82 risk assessment, screening, and counseling, 137, 138 Signa section, of prescription, 200 Signature section, of prescription, 201 Skin, review of, 107 Skin examination, 29 Sleep hygiene guide, 56 Smoking, 129–130 SOAP notes Assessment portion of, 52–54, 257 description of, 45, 257 diagnostic test results, 50, 54 differential diagnoses, 52, 53 follow-up instructions, 56, 58 interventions done during the visit, 50–51 laboratory tests, 54 Objective information portion of, 48–51, 257 patient education, 55–56 Plan portion of, 54–58 procedure note, 272–273 Subjective information portion of, 45–48, 257 therapeutic modalities, 55 Social history in admission history, 219, 221, 223 in adolescents, 102 in adults, 26–27 Social media, 187–188 Social Security number, 179 Soft diet, 232 Special instruction orders, 229, 234 Spinal accessory nerve, 30 Sports preparticipation physical examination, 106 Startle reflex, 108 STI See Sexually transmitted infection (STI) Stroke, 135 Subscription section, of prescription, 200 Substance abuse, 131–132, 133 Sudden death, 106 Surgery admissions, 260, 261–263 history and physical examination, 221–223 pre-operative evaluation of older adults, 162–164 Systems heading format, for documenting objective information, 50 T T-ACE questionnaire, 131 Telemedicine, 186 Telemetry, 221 Telephone communications, 183–185 Tertiary prevention, 125 Testes, 107 Therapeutic modalities, 55 Throat examination, 30 Timed Up and Go test, 162 Tinetti Performance Oriented Mobility Assessment tool, 162 Tobacco use, 129–130 Trigeminal nerve, 30 Trochlear nerve, 30 Trunk incurvation reflex, 108 Tuberculosis screening, 137 Type diabetes, 97–98 U U.S Preventive Services Task Force (USPSTF) hearing impairment screening, 159 medical conditions, 162 risk factor identification based on screening tests, 135–136 V Vaccinations See also immunizations older adults, 162 refusal of, 100 Vagus nerve, 30 Vegetarians, 128 Vision testing, 160, 161 Vital signs in admission history and physical examination, 220 admission orders, 227–228 monitoring, 258 objective information, 48 physical examination, 29 postoperative orders, 230 W Wandering, 293–294 Warnings section, of prescription, 201 Weber test, 161–162 Websites for medical education, 187 Well-child visits components of, 94, 97–106 description of, 93 Well-man examination, 138–139 Well-woman examination, 136–137 WHO See World Health Organization (WHO) Women screening for, 136–138 sports preparticipation physical examination for, 106 World Health Organization (WHO) growth standards, 94 health promotion, defined, 55 International Classification of Diseases (ICD), Y Youth at Risk Screening Questionnaire, 105 Copyright © 2019 by F A Davis Company All rights reserved 17_Sullivan_Index.indd 393 7/6/18 1:36 PM ... 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,... PMFSH 1995 Guidelines One body area or organ system Two to seven body areas or organ systems 1997 Guidelines One to five bulleted items Two to seven body areas or organ systems 12 to 17 bulleted... patient Failure to take an adequate history or to perform a detailed physical examination—or failure to recognize important findings—may lead to inadequate care of the patient Failure to document