Unit 5 Assignment Worksheet

Unit 5 Assignment Worksheet

Unit outcomes addressed in this Assignment:

• Analyze a medical record for errors or omissions that require the creation of a physician query.
• Develop appropriate physician queries to resolve data and coding discrepancies.

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CASE #ED322223

ED/ PROVIDER NOTE

PCP: Medical Center

Date of Arrival: 4/12/2014

Diagnosis: L AOM. Patient is very well-appearing and well-hydrated with no evidence of meningitis,

mastoiditis, pneumonia, or other SBI.

Disposition and Plan of Care:

-Discharge home

-Amoxicillin 620 mg PO BID x 10 days

-Follow-up and return precautions as per ACI

History of Present Illness: Source: Mother and sister

CC: RN, congestion, and ear pain

History of Present Illness: is a previously healthy 23 month old with tactile fever x 2 days with

ear pain since 0300 this morning. +RN and congestion for the past two days. Taking less PO than usual,

but urinating normally. No vomiting or diarrhea. No other concerns.

Past Medical History:

No prior hospitalizations

No prior surgeries

No ongoing medical conditions

Family History:

Negative for chronic childhood conditions

Social History:

Lives with parents and siblings

Medications:

Allergies: No Known Allergies

Immunizations Status: up to date

ROS:

Constitutional: fever

HEENT: RN, congestion, ear pain

Respiratory: negative

Cardiovascular: negative

ROS (cont’d):

Gastrointestinal: negative

Genitourinary: negative

Musculoskeletal: negative

Hematology/Lymphatic: negative

Skin: negative

Central Nervous: negative

PE:

Pulse 158 [crying] | Temp 98.2 | Resp 30 | Wt 15.3 kg, is alert, well developed, well nourished, in no acute distress

HEAD: normocephalic and atraumatic

EYES: pupils equal, round and reactive to light and extra-ocular movements intact

EARS: R TM is normal appearing. L TM bulging and erythematous with purulent effusion

NOSE: no discharge

OROPHARYNX: mucous membranes moist with no oral lesions

NECK: neck is supple with full active range of motion and no adenopathy

CHEST: clear to auscultation bilaterally and no wheezes, rales, or rhonchi

CARDIAC: regular rhythm, no murmurs and normal S1 and S2, no gallop

ABDOMEN: nondistended, soft, nontender to palpation , no hepatosplenomegaly, no masses, no guarding

or rebound tenderness and normoactive bowel sounds

BACK: exam deferred

GU: exam deferred

EXTREMITIES: brisk capillary refill and no edema

SKIN: no rashes and no petechiae

ASSIGNMENT DETAILS

Requirements:

Your assignment should have no more than 10% quoting.  Please use paraphrasing, in-text citation, and a list of references, as appropriate.

Your assignment should:

Unit 5 Assignment Chart Review & Physician Query

Chart reviewed: #ED322223

1. Describe the deficiency that was present in the health record and would require a physician query to resolve:

2. Compose a query to the physician to resolve the deficiency:

Unit 5 Assignment Grading Rubric: