Patient Name: Tyler Smith
MRN: 1257863
Dates of Service: 8/14/16—8/17/16
Attending Physician: Grant, James, MD
Query: Dr. Grant, the progress note dated 815 states that the patient has new onset of asthma. The progress notes on 8/16 states that the patient has chronic asthma with status asthmaticus, please advise me on the paper diagnosis.
Financial Impact: $542.24
Coder: Toni
INEFFECTIVE BREATHING PATTERN RELATED TO SWELLING AND SPASM OF BRONCHIAL TUBES IN RESPONSE TO INFECTION AS EVIDENCED BY COUGH, PROLONGED EXPIRATION, AND USE OF ACCESSORY MUSCLES.
GOAL
. CLIENT WILL MAINTAIN OPTIMAL BREATHING PATTERN AS EVIDENCED BY NORMAL BREATHING PATTERN.
2.INEFFECTIVE AIRWAY CLEARANCE RELATED TO INCREASED BRONCHIAL SECRETIONS AS EVIDENCED BY CHEST TIGHTNESS.
3.ACTIVITY INTOLERANCE RELATED TO FATIGUE AS EVIDENCED BY TIRED APPEARANCE.
4.FATIGUE RELATED TO RESPIRATORY DISTRESS AS EVIDENCED BY PROLONGED BREATHING.
5.INTERRUPTED FAMILY PROCESS RELATED TO EMERGANT HOSPITALISATION AS EVIDENCED BY EXCESSIVE WORRY.
Patient Name: Tyler Smith MRN: 1257863 Dates of Service: 8/14/16—8/17/16 Attending Physician: Grant, James, MD Query:...
Patient Name: Tyler Smith MRN: 1257863 Dates of Service: 8/14/16—8/17/16 Attending Physician: Grant, James, MD Query: Dr. Grant, the progress note dated 8/15 states that the patient has new onset of asthma. The progress notes on 8/16 states that the patient has chronic asthma with status asthmaticus, please advise me on the paper diagnosis. Financial Impact: $542.24 Coder: Toni