Question

CASE STUDIES IN HEALTH INFORMATION MANAGEMENT CASE 1-2 Problem-Oriented Medical Record Format Read the patient visit report shown in Figure 1-1 and answer the following questions. 1. What is the patient's chief complaint? 2. What information in the scenario is "subjective"? 3. What information in the scenario is "objective ? 4. Does Dr. Jenkins have a definitive assessment of Ms. Gerry's problem? If so, what is it? 5. What is the plan for this patient?

Answer 1

1. chief complaint : fall from wheelchair, complaining of severe pain in the left hip, intertronchanteric fracture of the left hip.

2. subjective information : complaint of severe pain in the left hip

3. objective information: X - ray findings , findings of physical assessment (shortened left leg and pedal pulses)

4. yes . Definitive assessment : X ray reveals intertronchanteric fracture and physical assessment shows shortening of the leg leg.

5. plan :

• seek medical clearance for surgery
• start Vitamin K to reduce the protime (because the patient is on Coumadine)
• apply Buck's traction
• open reduction and internal fixation of left hip if cleared from medical side for surgery.