AHIMA Professional Practice Experience Workbook

Exercise 30 Anatomy and Physiology and Disease Processes: IP Male 324789 Authentic Patient Records Instructions: Step 1 : Use the general directions from Exercise 6.0 to access the VLab Authentic Patient Cases. Review the patient record to identify and abstract information for each question. Create a case presentation: Step 2: Open a new slide presentation file and format the title slide with the title of this exercise, the course name, your full name, and your instructor’s name. Example of Title Slide Content: VLab Patient Cases A & P/Disease Processes Case 3.5 Introduction to Health Information Technology Johnny Jones Ms. Nora Smith

Step 3: Case Content: Create a 10-15 slide case summary for this patient, including information about the patient’s condition, disease and treatments provided (documented throughout the patient chart in Solcom EDMS), and the patient’s condition at the close of all episodes or documented encounters. Provide detailed information on the identified condition/disease from external references, including the outlook for the condition/disease progression, identifying the structures of the body typically affected, and treatments available for the condition. Presentation Content Criteria (page 2 and following): • Case type and gender, case number, age (or date of birth) & diagnosis (main reason for treatment) Ex: IP Male, 123456, Age 46 Lung Cancer

• Synopsis (summary) of patient encounters and treatment provided • Information about the condition and/or disease (from research)

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