Question

! leukocytopenia (WBC 2.1). LMP paliel Procedure results: ECG - Within normal limits GTT - Within normal limits Diagnosis: Scurvy Plan: Supplementation with vitamin C, 100 mg 3-5x/day until a total of 4 g is reached then 100 mg qid. Patient is counseled to have a diet rich in fruits and vegetables such as grapefruit, lemons, broccoli, green peppers, tomatoes and cabbage. Does the documentation in the chart support the medical necessity of the tests/procedures performed? Yes No If No, explain why

Answer 1

The documentation clearly states that the patient is diagnosed of having scurvy and is in need of the following treatment for recovery.To rule out the diagnosis a blood test for vitamin C is more important compared to a ECG (to rule out any heart problems ) or a GTT (to rule out diabetes)Hence the tests performed doesn't support the documentation in the chart.