Physician Query - Essay Example

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Please review the documentation in the patient medical record on the Discharge Summary (appended as Annexure I) to ensure coding compliance and accuracy. You are requested to address the query, include the missing information and return the query (duly dated and signed). The…
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Physician Query
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Download file to see previous pages HOSPITAL COURSE AND TREATMENT: The patient was admitted and started on Lovenox and nitroglycerin paste. The patient had serial cardiac enzymes and ruled out for myocardial infarction. The patient underwent a dual isotope stress test. There was no evidence of reversible ischemia on the Cardiolite scan. The patient has been ambulated. The patient had a Holter monitor placed but the report is not available at this time. The patient has remained hemodynamically stable. Will discharge.
Please review the documentation in the patient medical record on the Discharge Summary (appended as Annexure II) to ensure coding compliance and accuracy. You are requested to address the query, include the missing information and return the query (duly dated and signed). The query form will become a part of the physician’s documentation in the patient’s medical record.
INTERVENTIONS: A developmentally appropriate, group-oriented therapy program was the primary treatment modality. The attending psychiatrist provided evaluation for and management of psychotropic medications. The clinical therapist facilitated individual, group, and family therapy.
COURSE IN HOSPITAL: The patient was in the hospital from 06/11/09 until 07/13/09. The most prominent symptoms and behaviors while the patient was here were the following: Perceptual disturbances, strange thoughts, he was suspicious at times, at some point he was complaining of audiovisual hallucinations. He was quiet showing a flat affect, irritable, anxious and depressed moods, tearful at times, homesick, limited interaction with peers. He was attending groups, however, was showing limited participation. He was superficial, not really working too much on her issues, more focused on how soon she was going to be discharged more than working on her issues. He stated "strange feelings and sensations". The patient has shown some improvement in general. However, he is not completely stable yet, and he ...Download file to see next pagesRead More
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