PHYSICIAN QUERY PROCESS : QUESTION: Utilizing the patient record,…
Question PHYSICIAN QUERY PROCESS : QUESTION: Utilizing the patient record,… PHYSICIAN QUERY PROCESS:QUESTION: Utilizing the patient record, Please design 2 physician queries to address the conditions identified CT impressions. They could be yes/no, open-ended, or multiple choice to request clarification about documentation.Example of Multiple Choice Query:The patient, Frank Stauffer, is diagnosed with possible sepsis and CAP, Alcoholic dependence in remission, and a smoker. The vitals note that the patient has a blood pressure of 180/110. Can the blood pressure be further specified as:Attributed to Sepsis__________________Elevated Blood Pressure reading without a diagnosis of______Hypertension___________________Undetermined______________________patient’s record to utilize from:Patient Case Number: ED56-Stauffer, FrankPatient Name: Frank StaufferDOB: 08-10-62Sex: MDate of Service: 11-01-XXAttending Physician: Paul Morrows, MDReason for Visit: Abdominal/Chest painHistory of Present Illness:Mr. Stauffer is a 52-pack year smoker and presents with a complaint of abdominal/chest pain and SOB. Patient reports onset of symptoms about 2 weeks ago. Initially started as RUQ and right lower chest pain that was pleuritic in nature and associated cough. Patient states that about 3 days ago he had argument with friend and was punched in right upper abdomen. Since then, his pain has gotten significantly worse.Medical History: Alcohol Dependence in remission-attends AA every monthMedications: None Surgical History: None Review of Systems:Constitutional: Negative for fever, chills, activity change and appetite change.HENT: Negative.Eyes: Negative.Respiratory: Positive for cough and SOBCardiovascular: Positive for chest painGastrointestinal: Positive for abdominal pain. Negative for nausea and vomiting.Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative.Allergic/Immunologic: Negative.Hematological: Negative.Vitals:Temperature 98.9°FPulse 110Respirations 18Blood Pressure 180/110SpO2 92% on room airHeight 6’0ftWeight 178lbsBMI 24.1Physical Examination:Constitutional: He appears well-developed and well-nourished. No distress.HENT:Head: Normocephalic.Mouth/Throat: Oropharynx is clear and moist.Eyes: Conjunctivae are normal.Neck: Neck supple.Cardiovascular: Regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no friction rub. No murmur heard. tachycardiaPulmonary/Chest: Effort normal. Rhonchi right lower lobeAbdominal: There is Right upper and lower quadrant abdominal pain Skin: He is not diaphoretic.Nursing note and vitals reviewed.MDM:Number of Diagnoses or Management OptionsCAP (community acquired pneumonia) Chest pain, unspecified chest pain type, Sepsis, due to unspecified organism1) CAP/Sepsis-possible SIRS with 3/4 indicators (WBC 24, RR>20, HR >90)-blood cultures sent; started on ceftriaxone and azithromycin-patient 91 % on room air which improved to >94% on 4L NCCT of Chest and Abdomen IMPRESSION:1. Multilevel degenerative disc disease most significant at L3-L4 and L4-L5 with moderate spinal canal stenosis. Patient with loculated effusion possibly para-pneumonic vs hemothorax vs malignant effusion. Patient with total health and will likely be admitted to XYZ Hospital. Risk of Complications, Morbidity, and/or Mortality1. Possible Sepsis due to unspecified organism. Uncertain etiology and patient will require greater than 2 midnights to establish cause and manage illness.2. CAP.3. Alcoholism in remission.4. Smoker.Reference: https://journal.ahima.org/physician-query-examples/ Health Science Science Nursing CODING AND 1017 Share QuestionEmailCopy link Comments (0)
