Audit of Patient Health Record(1)
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School
American InterContinental University *
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Course
206
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
4
Uploaded by UltraQuetzalMaster248
Patient Health Records – Physician Office:
History: John Smith was taking care of his wife and son who both were diagnosed with COVID-19. John had only been able to get four hours of sleep in the last couple of days as he was responsible for cooking,
cleaning, and trying to maintain his job duties of an accountant while working remotely at home. John had not been taking his antihypertensive and diuretic medications as directed for the last couple of days.
He awoke to his wife’s screaming that she did not feel well and his son was needing something to drink. As John headed to his wife’s bedroom, he felt a sharp, squeezing chest pain. He soon noticed he was sweating profusely. His wife insisted that he call 911, but instead he drove himself to his attending physician’s office just 15 minutes away.
PFSH: John has a family history of CAD.
Physical Examination: The patient is a well-developed, well-nourished white male pale and diaphoretic. Vital Signs: HR 110, RR 20, temperature 99.1, BP 190/110. Heart: Irregular rate and rhythm. Lungs: Clear to auscultation. Extremities: The patient is complaining of right arm radiating pain.
EKG reveals ST elevation.
Impression: Abnormal electrocardiogram. Rule out myocardial infarction.
Plan: Admission to the hospital for observation and study.
Worksheet for Audit 1
Code
Correct or Incorrect
Explanation
R94.31
I25.10
Z82.49
99213
93000
History: Brandon was playing football upstairs at home with his sisters. His sister passed the football and Brandon dove to catch the ball but falling downstairs landing on his left wrist resulting in a swollen left forearm and his sister drove him to the ER.
Physical Examination: On examination, the left wrist is swollen, and the left hand is bent upward posteriorly. The entire left forearm is painful to touch.
X-rays: Three views were performed of the left wrist and revealed a complete fracture of the left distal radius. Impression: Colles’ fracture, distal left radius.
Procedure: The patient was given a regional block anesthesia and the distal left radius was reduced to will be taken to the operating room for closed reduction of the distal left radius. Two postoperative views
of the left forearm revealed normal alignment of the distal left radius.
Worksheet for Audit 2
Code
Correct or Incorrect
Explanation
S52.532A
Y92.009
W10.8XX
A
25605-RT
73110-LT
73090-LT
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