Documentation of medical record is critical to in noting specific facts, observations, and findings of a person’s health history including their present and past examinations, illnesses, tests, outcomes, and treatments. There is the chronological documentation of medical records where it shows the care a patient received that is important in determining high-quality care. A medical record is seen to facilitate the physician’s ability and healthcare professionals in planning and evaluating immediate treatment of patients while monitoring the patient’s overtime healthcare (Kikano, Goodwin & Stange, 2000). The records also assist in continuity of care and communication among health care professionals and physicians involved in the patient’s care. Documentation is used during the determining of payment and claims. It is also used during quality care evaluations and review of appropriate utilization. Data from documentation can also be used to carry out research and education. It is therefore critical that each medical facility observes their documentation to avoid hassles and can act as a legal document to prove that the patient was given quality care.
CMS Guidelines on Documentation
There are CMS guidelines for documentation of a comprehensive history and physical (H&P). The guidelines are well stipulated in the evaluation and management services documentation guidelines of 1997. Using the guidelines stipulated a comparison will be done with the case study presented in the assignment to determine whether documentation was done appropriately and in order as required. The case is that of a patient known as Anne Smith who happens to be a new patient presenting an internal medicine office-based practice (Kikano, Goodwin & Stange, 2000). The documentation of her history is done by Carly Sanders, an experienced nurse practitioner. An evaluation of the H&P is to be done to understand whether the documents meet the guidelines, identify errors, if the assessment relates to history, identify any missing diagnosis or conditions and determine whether the plan is reasonable according to the assessment.
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Firstly, is to find out if the document meets the CMS guidelines for documentation of a comprehensive history and physical. The case presented is authored by Carly Sanders, and according to the evaluation and management services documentation guidelines of 1997, the document is in order. It has a proper description of the history where it includes; chief complaint, HPI, ROS and past family or social history. Such information is critical to understanding the patient’s origin of the disease and other factors leading to the illness (Kikano, Goodwin & Stange, 2000). There are types of history used which include: problem-focused, focused expanded problem, comprehensive and detailed. Type of history will assist in understanding the patient depending on their current condition. In the case study discussed, it is clear that the chief complaint is stated as a follow up after emergency department visit. A chief complaint is a report used to describe the problem, diagnosis or recommended return by physician usually phrased according to the words of the patient.
History of present illness is a consecutive description of how the patient’s present condition developed from the initial symptoms or previous encounter to the current status. Elements to be mentioned are location, symptoms, quality, associated signs, severity, modifying factors, duration, context and timing (Kikano, Goodwin & Stange, 2000). The history of present illness in the case of discussion is also well stipulated showing the history in relation to a report presented to the emergency department. It shows symptoms of coughs and short breaths, duration of two weeks and context of what was administered in the beginning. Therefore, one can say that the history of present illness was well stipulated.
Review of systems is a form of record of systems of the body which is acquired through questioning of the patient. The aim of questioning a patient is to identify any symptoms or signs that may be experienced or experiencing. Review of systems used is determined by the history of present illness in that the HPI will determine the questions asked during ROS (Kikano, Goodwin & Stange, 2000). In the case of discussion, it is clear to say that the documentation was done appropriately for the nurse conducted a ROS in accordance to the HPI which is characterized by respiratory problems. Past family or social history is also critical for medical documentation. It shows the past illness of the patient, family relation to certain medical condition or social history where the age and activities contribute to the current illness. Such information is also well displayed in the case above by Carly Sanders, the nurse. Therefore, in general, the documentation is done in accordance with the guidelines of a comprehensive history and physical.
Analysis of H&P
Critical analysis of the H&P is needed, and a list of any errors found in the case presented. In the case discussed the H&P is well done with the history detailed to assist in understanding the cause. History first shows that the chief complaint which is critical as discussed above for it is written according to the patient’s description. A history of the present illness is also well done where Carly Sanders shows the symptoms, duration, timings, severity, and context. Review of systems is also well done with focus made on the history of present illness (Kikano, Goodwin & Stange, 2000). As discussed earlier, ROS is dependent on HPI. There is also a brief history of the past, family, and social environment. It is seen that there is a trend in respiratory issues in the family. The age of the patient is also stipulated to assist in understanding the patient’s history. Examinations were not done to understand the expanded problem. As seen in the case, the patient has a respiratory condition where the ROS are mainly questions that the patient answers. An examination would require the use of medical equipment to gain the required data. The document only shows evidence of a ROS conducted with its objective well displayed and assessment done. For the document to be considered correct, it would be advisable to have an examination report.
Various questions may not have been answered through the H&P given in the case discussed. Firstly, the test is done to verify the present status of the HPI. It is critical that examinations are done on the patient to understand how severe is the condition (Kikano, Goodwin & Stange, 2000). Secondly is the assessment according to the examination that will assist in knowing the current status and what is required to help the patient. In the case above all, it has been the history, objectives, and assessment. The plan is not stipulated, and it could be because there were no tests conducted.
Assessment and HPI Relation
The information given in the assessment section seem to relate with those found in the history of present illness. Reason to support the document is that Carly Sanders states that the patient has been diagnosed with bronchitis several times in the previous year. The patient had a problem with shortness of breath and coughs. Tests done led to the conclusion that the patient was suffering from bronchitis and was asked to take Albuterol MDI (Kikano, Goodwin & Stange, 2000). The medication seems not to be working for her for the coughs, and shortness of breath are still persistent. The assessment then shows that the patient may have persistent asthma with acute exacerbation, pneumonia, hypertension, hyperlipidemia, and obesity. According to the shortness of breath, there may be an issue with weight hence obesity while asthma is also related to shortness of breath and coughs. Some scientists believe that bronchitis and asthma are related and the main difference is the medication used to open up the lungs for breathing purposes. Therefore, one could say that there is a reasonable relationship between the assessment and history of previous illness.
Other Diagnoses
Other differential diagnoses or conditions that would be included in the assessment include pulmonary conditions such as pulmonary disease and interstitial lung disease. Such a condition is seen to affect the lungs and respiratory system at large (Bastable, 2003). It affects the patient’s ability to breath in and one may have difficulty breathing and may witness wheezing just as stated in the objective of the case. They are seen to possess symptoms such as short of breath and persistent coughs. The conditions also may be related to bronchitis and asthma which are also listed in the HPI and assessment respectively.
ICD-10 Codes
There are ICD-10 codes used in the medical field of various findings. Firstly, is the moderate persistent asthma with (acute) exacerbation whose ICD-10 code is J4541. Secondly is pneumonia, an unspecified organism whose ICD-10 code is J64. Thirdly, is essential (primary) hypertension whose ICD-10 code is l10 (Kikano, Goodwin & Stange, 2000). Fourth is hyperlipidemia unspecified whose ICD-10 is E785. Finally, is obesity whose ICD-10 code is E66.9.
Billing of Pneumonia
It is advised that one includes the ICD-10 code for pneumonia during the billing the visit. The reason as to why it should be included in the billing is because the patient has not been treated for the condition and therefore it is an initial encounter. In a situation where the same comes up in future, one would say that the ICD-10 code should not be included in the billing because it is not an initial encounter. Therefore, pneumonia should be billed in the case of discussion for bronchitis was the only one treated initially (Kikano, Goodwin & Stange, 2000).
Assessment and Plan Relation
The given plan in the case of discussion is reasonable as compared to the assessments presented. There cannot be a Dx plan because there were no examinations that were done in regards to the patient’s condition. There are education strategies that may be used in teaching the patient on how to maintain their medical condition or on medication. Firstly, is the use of written material especially those that are specially made for patients (Owens, 2010). The print should be well tailored to ensure that the patient easily understands with simple English. Complicated medical terms should not be used to avoid confusing the patient. It should be written from a reading level perspective where the general population may comprehend what is being discussed. It is also critical that information packages are readily available for new patients. Secondly is the verbal instruction where the health care provider should have a one on one discussion with the patient on how to manage their condition while showing them the advantages of medication taken. Lastly is demonstration how the medication works in that the healthcare provider should demonstrate using dummies of organs on how the medicine will assist in easing breathing for the patient. It will help the patient to understand the use of the medicine better (Bastable, 2003).
References
Bastable, S. B. (2003). Nurse as educator: Principles of teaching and learning for nursing practice . Jones & Bartlett Learning.
Kikano, G. E., Goodwin, M. A., & Stange, K. C. (2000). Evaluation and management services: a comparison of medical record documentation with actual billing in community family practice. Archives of family medicine , 9 (1), 68.
Owens, D. K., Lohr, K. N., Atkins, D., Treadwell, J. R., Reston, J. T., Bass, E. B., ... & Helfand, M. (2010). AHRQ series paper 5: grading the strength of a body of evidence when comparing medical interventions—Agency for Healthcare Research and Quality and the Effective Health-Care Program. Journal of clinical epidemiology , 63 (5), 513-523.
