ase read the clinical patient record, all the sections, and complete the purple lavender sections throughout the dinical record. A-Assessment 9/10 Reason for Nutrition Assessment: 65 YOM ADMITTED FOR HYPERGLYCEMIA. REFERRED TO RDN FROMP PCP FOR DIABETES NUTRITION EDUCATION. Client History (CH): note which diagnosis is the primary or admitting diagnosis CH-2.11 Patient chief nutrition complaint: HUNGRY/THIRSTY AND WANTS MORE FOOD AND DRINKS EVEN AFTER EATING/DRINKING CH-1.1.1 CH-1.1.3 CH-114 CH-1.16 Age: 65 Sex MALE Race: CAUCASIAN Language: ENGLISH Patient/Client/Family Medical/Health History: CH-2.1.1 Patient chief nutrition complaint: HUNGRY/THIRSTY AND WANTS MORE FOOD AND DRINKS EVEN AFTER EATING/DRINKING CH-2.1.3 Endocrine/metabolism: DM2 DIAGNOSED UPON ADMISSION Social History: CH-3.1.2 CH-3.14 CH-3.15 Living/housing situation (specify) UVES WITH WIFE Social and medical support (specify): WIFE DOES COOKING Geographic location of home (specify): LAS CRUCES Anthropometric Measurements (AD): AD-1117 AD-1.12.1 Stated Height: 188 CM (6'2") Measured Weight: 102 KG (225#) AD-1.15.1 BMI 28.9 OVERWEIGHT Nutrition Focused Physical Findings (PD) PD-115 PD-1.1.5.21 Digestive system: PT WITH GOOD APPETITE AND REPORTED EATING ALL OF HIS MEALS Increased appetite: PER PATIENT REPORT PD-1.1.13.16 Excessive thirst: PER PATIENT REPORT Vital signs: PD-1.1.21.5 PD-1.1.21.6 PD-1.1.21.7 Pulse rate: 85 BPM Respiratory Rate: 15 BREATHS PER MINUTE Temperature: 37 CELSIUS Food/Nutrition Related History (FH) Oral fluid estimated intake in 24 hours: 2300-2500 ML FLUID/DAY Estimated amount of food: 100% OF TRAY FH-1.2.1.1 FH-1.2.2.1 FH-1.2.2.2 Types of food/meals: PRE-SELECT MENU FH-1.2.2.3 FH-2.11.2 Modified diet order: CONSISTENT CARB ON 04/25 Meal/snack pattern: 3-5 MEALS PER DAY AT HOME DM2 Case Study Patient Data Anthropometrics Height: 6'2" Weight: 225 lbs Mr. Abdullah Oblongata DOB: 05/05/1955 New Mexico State University Dietetic Internship Labs Glucose Diet Meds Intake Consistent -Lantus 100% of tray Carbohydrate Day 1: 350, 287,250, -Novolog 2,300-2,500 300 Sliding Scale mL/day Day 2: 285, 220, 230, 215

ase read the clinical patient record, all the sections, and complete the purple lavender sections throughout the dinical record. A-Assessment 9/10 Reason for Nutrition Assessment: 65 YOM ADMITTED FOR HYPERGLYCEMIA. REFERRED TO RDN FROMP PCP FOR DIABETES NUTRITION EDUCATION. Client History (CH): note which diagnosis is the primary or admitting diagnosis CH-2.11 Patient chief nutrition complaint: HUNGRY/THIRSTY AND WANTS MORE FOOD AND DRINKS EVEN AFTER EATING/DRINKING CH-1.1.1 CH-1.1.3 CH-114 CH-1.16 Age: 65 Sex MALE Race: CAUCASIAN Language: ENGLISH Patient/Client/Family Medical/Health History: CH-2.1.1 Patient chief nutrition complaint: HUNGRY/THIRSTY AND WANTS MORE FOOD AND DRINKS EVEN AFTER EATING/DRINKING CH-2.1.3 Endocrine/metabolism: DM2 DIAGNOSED UPON ADMISSION Social History: CH-3.1.2 CH-3.14 CH-3.15 Living/housing situation (specify) UVES WITH WIFE Social and medical support (specify): WIFE DOES COOKING Geographic location of home (specify): LAS CRUCES Anthropometric Measurements (AD): AD-1117 AD-1.12.1 Stated Height: 188 CM (6'2") Measured Weight: 102 KG (225#) AD-1.15.1 BMI 28.9 OVERWEIGHT Nutrition Focused Physical Findings (PD) PD-115 PD-1.1.5.21 Digestive system: PT WITH GOOD APPETITE AND REPORTED EATING ALL OF HIS MEALS Increased appetite: PER PATIENT REPORT PD-1.1.13.16 Excessive thirst: PER PATIENT REPORT Vital signs: PD-1.1.21.5 PD-1.1.21.6 PD-1.1.21.7 Pulse rate: 85 BPM Respiratory Rate: 15 BREATHS PER MINUTE Temperature: 37 CELSIUS Food/Nutrition Related History (FH) Oral fluid estimated intake in 24 hours: 2300-2500 ML FLUID/DAY Estimated amount of food: 100% OF TRAY FH-1.2.1.1 FH-1.2.2.1 FH-1.2.2.2 Types of food/meals: PRE-SELECT MENU FH-1.2.2.3 FH-2.11.2 Modified diet order: CONSISTENT CARB ON 04/25 Meal/snack pattern: 3-5 MEALS PER DAY AT HOME DM2 Case Study Patient Data Anthropometrics Height: 6'2" Weight: 225 lbs Mr. Abdullah Oblongata DOB: 05/05/1955 New Mexico State University Dietetic Internship Labs Glucose Diet Meds Intake Consistent -Lantus 100% of tray Carbohydrate Day 1: 350, 287,250, -Novolog 2,300-2,500 300 Sliding Scale mL/day Day 2: 285, 220, 230, 215

3-2-1 Code It

6th Edition

ISBN:9781337660549

Author:GREEN

Publisher:GREEN

Chapter6: Icd-10-cm Outpatient And Physician Office Coding

Section: Chapter Questions

Problem 6MC

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