The purpose of this paper is to understand the importance of accurate medical record documentation to record pertinent facts, findings, and observations about a patient’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.
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Step 1:
Review and critique the comprehensive H&P and thoroughly answer the questions that follow in complete sentences and paragraphs using question and answer APA format.
Step 2:
Use current APA format to style your paper and to cite your sources. Your source(s) should be integrated into the paragraphs. Use internal citations pointing to evidence in the literature and supporting your ideas. Include a title page and a reference page listing the sources you used.
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Step 3:
Keep in mind the requirements set forth in the 1997 Guidelines of Documentation for Evaluation and Management by CMS. Visit CMS.gov, and then search \”1997 Guidelines of Documentation for Evaluation and Management\” for information that should be included in a medical record.
Answer the following questions:
1. Does this document meet the CMS guidelines for documentation of a comprehensive history and physical? Why or why not? Be specific.
2. Critically analyze the H&P and list any errors. Identify the strengths of the H&P.
3. Did any questions come to mind that you are unable to answer after reading the H&P?
4. Are the conditions listed in the assessment section reasonably supported by the history? Why or why not? Explain your rationale.
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5. Did you identify other differential diagnoses or conditions that should be included in the assessment? If so, list them.
6. List the ICD-10 code for each of the following (go to CMS.gov and search for the ICD-10 Codes):
Moderate persistent asthma with (acute) exacerbation: ______________
Pneumonia, unspecified organism: ______________
Essential (primary) hypertension: ______________
Hyperlipidemia, unspecified ______________
Obesity: ______________
7. Is it appropriate to include the ICD-10 code for pneumonia when billing for this visit? Why or why not?
8. Is the plan reasonable based on the assessments listed? Why or why not?
9. List 3 patient education strategies relevant to the case study including specific medication teaching. Include references.
10. List health promotion recommendations from AHRQ according to age/gender/conditions. Cite your references.
MODEL ANSWER
Comprehensive H&P Case Study
1. Whether the document meets the CMS Guidelines for Documentation
This document meets the CMS guidelines for documentation of a comprehensive | PLACE YOUR ORDER NOW AT writtask.com | of office to be offered, the first three components to be considered are the history, medical decision-making and | PLACE YOUR ORDER NOW AT writtask.com | documentation guidelines meet the needs of a typical | PLACE YOUR ORDER NOW AT writtask.com | groups like the children and infants, the recorded information may be different due to extra information put in the examination or the recorded area.
2. H&P Analysis and Errors
No errors were evident in the document showing that the H & P | PLACE YOUR ORDER NOW AT writtask.com | and the physical examination are important as they can provide important information obtainable through different | PLACE YOUR ORDER NOW AT writtask.com | listening and use of open-ended questioning while interacting with the patient will play an important role in providing remarkable ideas about the problems depicted by | PLACE YOUR ORDER NOW AT writtask.com | than being the oldest diagnostic tools, doing a comprehensive patient assessment can help address healthcare concerns of the patient (Lockey, 2014). The patients also need to be n charge of their own healthcare plan by asking pertinent questions regarding the instituted healthcare intervention. Involving patients in their own healthcare plan can help to guarantee the provision of evidence-based and cost-effective care.
3. Whether any Questions came to mind
Yes, since the patient was complaining of severe cough as well as possible shortness of breath besides being diagnosed with | PLACE YOUR ORDER NOW AT writtask.com | has Albuterol as the possible medication without any possible relief. Consequently, the question that comes to mind include what could be the | PLACE YOUR ORDER NOW AT writtask.com | misdiagnosis or it is the medication that has a problem?
4. Whether the conditions listed in the assessment section is supported by history
The patient listed in the assessment section isn’t | PLACE YOUR ORDER NOW AT writtask.com | of dry cough but the assessment shows that the patient has a good history of good | PLACE YOUR ORDER NOW AT writtask.com | vital signs, the patient’s RR is 22 and she complains of having shortness of breath after | PLACE YOUR ORDER NOW AT writtask.com | RR needs to be more than 22 when the patient has a history of dyspnea. Furthermore, the PR is normal with no history of palpitations. It is however expected that the pulse rate is above the normal due to compensatory measures.
5. Other Differential Diagnosis/conditions to be part of the assessment
The differential diagnosis/conditions that | PLACE YOUR ORDER NOW AT writtask.com | assessment is Bronchitis and Emphysema or COPD can as well be taken as part of differential diagnosis as they also prevent wheezing, breathing challenges and intense cough.
6. Moderate persistent asthma with (acute) exacerbation: J45.41
Pneumonia, unspecified organism: J18.1
Essential (primary) hypertension: R03.0
Hyperlipidemia, unspecified: E78.5
Obesity: E66
7. Whether it is appropriate to include the ICD-10 code for Pneumonia
It is not appropriate to include the ICD-10 | PLACE YOUR ORDER NOW AT writtask.com | assessment and history, the patient doesn’t have | PLACE YOUR ORDER NOW AT writtask.com | shows that there is no data that can support the presence of pneumonia. For instance, the patient doesn’t have fever while pneumonia is known to have a correlation | PLACE YOUR ORDER NOW AT writtask.com | also demonstrate a wheezing sound that is associated more with asthma and COPD rather than pneumonia. Often, pneumonia is associated with increase in secretions as reflected in the reflected cough.
8. Whether the plan is reasonable based on the listed assessments The plan s partly | PLACE YOUR ORDER NOW AT writtask.com | be said to be not reasonable since it doesn’t have a diagnostic plan that can help to explore the patient’s real | PLACE YOUR ORDER NOW AT writtask.com | diagnosis shows that the patent could be having bronchitis or COPD, it is right to incorporate spirometry as well as peak expiratory flow rate which is one of the critical diagnostic procedures. Such a procedure will help to identify whether the patient has asthma | PLACE YOUR ORDER NOW AT writtask.com | plan can as…
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