CCO Admin asked:
Can some one please help me code this kind of chart I usually get stuck and really do not know where to even start. or if there are any classes I can take to learn how to do these inpatient multiple codes. I am studying for my CCS and these kinds of charts SCARE ME because I am not working in the field yet. PLEASE HELP!!!
INPATIENT RECORD HISTORY AND PHYSICAL EXAMINATIONPROGRESS NOTESPHYSICIANS ORDERSLABORATORY REPORTSMICROBIOLOGYLABORATORY RESULTSMICROBIOLOGYMICROBIOLOGYRADIOLOGY REPORTRADIOLOGY REPORT
PATIENT 7
DISCHARGE SUMMARY
DATE OF ADMISSION: 9/8 DATE OF DISCHARGE: 9/10
DISCHARGE DIAGNOSIS:
Acute pyelonephritis
Septicemia; resistant to ampicillin and penicillin
ADMISSION HISTORY: This 21-year-old female was admitted to the hospital with discomfort in the right side. Other than this she has been healthy. On the day of admission she developed severe discomfort in the lower back. She was having fever and chills for which she took an aspirin and then she came to the emergency department.
COURSE IN HOSPITAL: The patient was treated with intravenous antibiotics in the form of gentamicin and cefoxitin. She continued to improve on this regimen and became afebrile after about three days of treatment. Her physical examination remained essentially unchanged; however; there was marked improvement in the patients general condition. The patient also had an onset of herpes simplex infection on her upper lip; for which she was given Zovirax ointment.
INSTRUCTIONS ON DISCHARGE: The patient was discharged home on ciprofloxacin 500 mg p.o. b.i.d.
Can some one please help me code this kind of chart I usually get stuck and really do not know where to even start. or if there are any classes I can take to learn how to do these inpatient multiple codes. I am studying for my CCS and these kinds of charts SCARE ME because I am not working in the field yet. PLEASE HELP!!!
INPATIENT RECORD HISTORY AND PHYSICAL EXAMINATIONPROGRESS NOTESPHYSICIANS ORDERSLABORATORY REPORTSMICROBIOLOGYLABORATORY RESULTSMICROBIOLOGYMICROBIOLOGYRADIOLOGY REPORTRADIOLOGY REPORT
PATIENT 7
DISCHARGE SUMMARY
DATE OF ADMISSION: 9/8 DATE OF DISCHARGE: 9/10
DISCHARGE DIAGNOSIS:
Acute pyelonephritis
Septicemia; resistant to ampicillin and penicillin
ADMISSION HISTORY: This 21-year-old female was admitted to the hospital with discomfort in the right side. Other than this she has been healthy. On the day of admission she developed severe discomfort in the lower back. She was having fever and chills for which she took an aspirin and then she came to the emergency department.
COURSE IN HOSPITAL: The patient was treated with intravenous antibiotics in the form of gentamicin and cefoxitin. She continued to improve on this regimen and became afebrile after about three days of treatment. Her physical examination remained essentially unchanged; however; there was marked improvement in the patients general condition. The patient also had an onset of herpes simplex infection on her upper lip; for which she was given Zovirax ointment.
INSTRUCTIONS ON DISCHARGE: The patient was discharged home on ciprofloxacin 500 mg p.o. b.i.d.
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