Complete Case Study 1.15 Special Health Record Documentation Requirements on pg. 30-31 in the Health Information Managem

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Complete Case Study 1 15 Special Health Record Documentation Requirements On Pg 30 31 In The Health Information Managem 1 (60.63 KiB) Viewed 49 times

Complete Case Study 1.15 Special Health Record Documentation Requirements on pg. 30-31 in the Health Information Management Case Studies (Foley) textbook. Read the case scenario and answer the questions accordingly. Refer to Chapter 4 in the Health Information Management Technology: An Applied Approach (Sayles & Gordon) textbook for additional information on health record documentation requirements by settings. To help with the CPT code verification part of the assignment, try conducting an internet search on E&M codes. Make sure to cite your resources in the assignment.
Competency 1.4 1. You have been asked to audit a pediatric group's medical records. In addition to verifying the appropriate E&M code assigned, you are tasked with ensuring that all relevant documentation is present in the record. a. Use the scenario and checklist that follow to determine if all relevant documentation is present in the record including discharge status. b. Verify the E&M code assigned. If the code is incorrect, select the appropriate code. Defend your selection whether you determine it is correct or incorrect. OFFICE NOTE: 7/15/19 Timothy is a nine-month-old male who presents today with bilateral earaches. Timothy's mother states that the child has been crying and pulling at his ears for the last two days. She has also noticed a mild fe ver. Otoscopic examination revealed bulging tympanic membranes indicative of fluid buildup. Amoxicillin prescribed for ear infection. Script e-faxed to pharmacy. CPT code assignment for visit: 99202 BIRTH HISTORY 10/09/18 Timothy had an uneventful, full-term, vaginal birth. Uncomplicated pregnancy, natural child- birth. No forceps used in delivery. APGAR score at birth 8, repeat APGAR 10. PERSONAL, SOCIAL, AND FAMILY HISTORY 11/10/18 Second child, one older sister who is four years old. Parents are married. Non-smoking cnvironment. No pets in the home. Will attend daycare after mother's maternity leave ends in three months. Circumsized prior to discharge at birth. NUTRITIONAL HISTORY 11/10/18 Timothy is breastfed initially. 12/13/18 Breastfeeding continues. 2/16/19 Breastfeeding continues. 4/18/19 Cereal has been introduced into diet, rice. MEDICATIONS 7/15/19 Amoxicillin BID for 10 days. CHECKLIST Office note-well-child or medical issue Birth history Nutritional history Personal, social, and family history Growth and development record Immunizations Medications Discharge status 7/15/19 Infant eats rice and oatmeal cereal, variety of fruits. No reactions noted to new foods. OFFICE NOTE: 11/10/18 Well-child visit. No problems. Child thriving. Growth appropriate. OFFICE NOTE: 12/13/18 Well-child visit. No problems. Growth appropriate. First set of vaccines administered. OFFICE NOTE: 2/16/19 Well-child visit. No problems. Growth appropriate. Developmental milestones met. Second set of vaccines administered OFFICE NOTE: 4/18/19 Well-child visit. No problems. Growth appropriate. Developmental milestones met. Third set of vaccines administered.