Exercise 36 Linking Diagnoses with Clinical Documentation: ED Male 322230 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 #: 36 Patient Name: MPI: Patient Type: Chief Complaint or Reason for Admission:
Review the HPI section of the physician’s note. Does the patient have a history of similar episodes? If abbreviations are used in the note, write out the full words.
What findings noted during the exam confirm or rule out the suspected diagnosis?
Describe the plan (include prescriptions, follow-up): 1. 2. 3. 4. 5.
Discharge Diagnosis: 1. 2. 3. 4. 5. Discharge Instructions:
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