HCS 216 Week 3 Musculoskeletal System – Analyzing a Progress Note

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HCS 216 Week 3 Musculoskeletal System – Analyzing a Progress Note
Complete the University of Phoenix Material: Musculoskeletal System - Analyzing a Progress Note.

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Musculoskeletal System – Analyzing a Progress Note

 

Part 1

 

Using the following progress note, define the bolded terms within the chart provided. 

 

This patient is being treated in a local outpatient physical therapy office.

 

Progress Note

 

Patient is a 55 y.o. male who returns for session 3/10 outpatient therapy.

 

History: Patient has a history of arthritis (unspecified) to the cervical spine, fibromyalgia, and osteoarthritis. Patient is 4 weeks post-operative right femur surgery following a greenstick fracture after falling on the ice. Patient had a post-operative MRI last week. Report attached.

 

Subjective: The patient states his pain is moderate level 4/10. He notes his function is improving and he is now ambulating with a cane.

 

Strength:

Adduction: 2/3

Abduction: 2/2

Knee extension: 2/2 painful

Knee flexion: 3/2 painful

Plan: Continue with physical therapy sessions as per plan.

 

Diagnosis: Femur shaft fracture

 

Julie Brush, PT

*Do not forget to include the sources for your definitions.
Medical term
Definition
Sources
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Part 2

 

Complete the following table using the information found in the Progress Note and the Internet. List the appropriate code(s) for the given medical terms and provide a justification explaining why you selected the given medical code(s).

 

Medical term
Medical code
Justification
Sources
Femur shaft fracture

(stress fracture, unspecified femur)
 
 
 
Rheumatoid Arthritis

unspecified
 
 
 
Osteoarthritis

(Polyosteoarthritis unspecified)
 
 
 
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