H&P Comprehensive study

The purpose of this paper is to understand the importance of accurate medical record documentation to record pertinent facts, findings, and observations about a patient’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.
Directions:

Step 1:

Review and critique the comprehensive H&P (H& P IS ATTACHED IN SEPARATE FILE) and thoroughly answer the questions that follow in complete sentences and paragraphs using question and answer APA format.

Step 2:

Use current APA format to style your paper and to cite your sources. Your source(s) should be integrated into the paragraphs. Use internal citations pointing to evidence in the literature and supporting your ideas. Include a title page and a reference page listing the sources you used.

Step 3:

Keep in mind the requirements set forth in the 1997 Guidelines of Documentation for Evaluation and Management by CMS. Visit CMS.gov, and then search \”1997 Guidelines of Documentation for Evaluation and Management\” for information that should be included in a medical record.

Answer the following questions:

1. Does this document meet the CMS guidelines for documentation of a comprehensive history and physical? Why or why not? Be specific.

2. Critically analyze the H&P and list any errors. Identify the strengths of the H&P.

3. Did any questions come to mind that you are unable to answer after reading the H&P?

4. Are the conditions listed in the assessment section reasonably supported by the history? Why or why not? Explain your rationale.

5. Did you identify other differential diagnoses or conditions that should be included in the assessment? If so, list them.

6. List the ICD-10 code for each of the following (go to CMS.gov and search for the ICD-10 Codes):

Moderate persistent asthma with (acute) exacerbation: ______________

Pneumonia, unspecified organism: ______________

Essential (primary) hypertension: ______________

Hyperlipidemia, unspecified ______________

Obesity: ______________

7. Is it appropriate to include the ICD-10 code for pneumonia when billing for this visit? Why or why not?

8. Is the plan reasonable based on the assessments listed? Why or why not?

9. List 3 patient education strategies relevant to the case study including specific medication teaching. Include references.

10. List health promotion recommendations from AHRQ according to age/gender/conditions. Cite your references.

Your paper should be 3-4 pages not including the title and reference pages. A minimum of 2 sources, not including your texts, must be incorporated into your paper.
Use current APA format to style your paper and to cite your sources. Your source(s) should be integrated into the paragraphs. Use internal citations pointing to evidence in the literature and supporting your ideas. Include a title page and a reference page listing the sources you used.

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