Chart analysis- instruction- select any four items and explain the importance of analyzing the item.
Admission Diagnosis
Final Diagnosis
Are the Progress notes legible? Summarize one note
Operative Report
Post op Diagnosis
List the procedure
Doctor’s orders
Signed/dated/timed???
List and review two lab results-
Are the results low or high?
Review the final nursing notes
Discharge instructions given to the patient?
List an example
Review the H&P
List Past Medical conditions/illness/diseases
Clinical Impression???
Discharge Disposition
Chart analysis- instruction- select any four items and explain the importance of analyzing the item. Admission...
Because performance improvement activities are information intensive, organizations must provide the proper resources and systems to support improvements. It’s important to recognize that PI programs need to meet accreditation standards such as The Joint Commission and Medicare and Medicaid Conditions of Participation, which require access to national comparative data collections. This assignment, based on a textbook case study, will help students to understand Joint Commission information management standards by analyzing how a scenario relates those standards. Instructions Your assignment will...
Because performance improvement activities are information intensive, organizations must provide the proper resources and systems to support improvements. It’s important to recognize that PI programs need to meet accreditation standards such as The Joint Commission and Medicare and Medicaid Conditions of Participation, which require access to national comparative data collections. This assignment, based on a textbook case study, will help students to understand Joint Commission information management standards by analyzing how a scenario relates those standards. Instructions Your assignment will...
Q: Need help with this outpatient case to code diagnosis and CPT/HCPCS codes Case: 410057, Female, Age-57 Department of Surgery Interval History and Physical Note Admission Date and Time: 3/19/2014 5:57 AM Preoperative Diagnosis: invasive ductal carcinoma of the right breast Pertinent laboratory tests: hct 44, Cr 0.8, INR 1.0 Procedure: Right segmental mastectomy with sentinel lymph node biopsy, and breast reconstruction Surgeon: Specific counseling: given in clinic H&P documentation: I have examined the patient...