Exercise 35 Linking Diagnoses with Clinical Documentation: IP Female 400233 Authentic Patient Cases Instructions: Access the VLab Authentic Patient Cases. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment. For injuries, document the place and nature of the injury. For surgical cases, review for surgical consent, and participation of anesthesiologist. Exercise #: 35 Patient Name: MPI: Patient Type: Chief Complaint or Reason for Admission:
Review the HPI Section of the Hospitalist’s report. Which phrases from the HPI relate directly to the syncope episode?
What other significant findings does the hospitalist note during the exam?
Review the hospitalists’ assessment and plan. What are the conclusions regarding the syncope?
Discharge Diagnosis: 1. 2. 3. 4. 5. 6. 7.
Physician Orders:
Status:
Link to Dx #
1.
Copyright ©2020 by the American Health Information Management Association. All rights reserved.
Powered by FlippingBook