HCS 214 Week 5 Urinary System–Analyzing a Progress Note

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HCS 214 Week 5 Urinary System–Analyzing a Progress Note
Complete the University of Phoenix Material: Urinary System-Analyzing a Progress Note.

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Urinary System – Analyzing a Progress Note


Part 1


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


This patient is a resident in a Nursing Home and is being assessed by a local doctor.


Progress note:


Patient is a 68 y.o. male with history of kidney stones, urinary tract infection (UTI) and diabetes insipidus. Nursing staff reports a change in mental status, foul smelling urine, and increased incontinence with complaints of pain with urination.


On examination patient is alert. Patient notes having increased pain with urination and burning along with extreme pain in the lower abdomen at times. A urine culture was positive for e-coli bacteria. The urinalysis is positive for WBCs, RBC, and increased pH with results favorable for stone formation.


Plan to start Macrobid, increase fluid intake, repeat urinalysis and kidney function in the morning. Please catheterize the patient. Portable ultrasound in am. If positive will discuss possible cystoscopy and nephrology referral.


Impression: UTI, kidney stone


D. George, M.D.


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


Using the information in the progress note, decide which code correctly represents the diagnosis. Underline the code of your choice.


Medical term
Medical code
Urinary Tract Infection (UTI)
N39.0 Urinary tract infection, site not specified


P39.3 Urinary tract infection of newborn


N99.89 Other postprocedural complications and disorders of the genitourinary system


N36.9 Urethral disorder unspecified

Diabetes insipidus
N25.1 Nephrogenic diabetes insipidus


E23.2 Diabetes insipidus


P70.2 Neonatal diabetes mellitus


E11.9 Diabetes mellitus without complications
Kidney stone
N28.1 Cyst of kidney, acquired


S37.009A Injury to kidney without mention of open wound into cavity, unspecified injury, initial encounter


D30.00 Benign neoplasm of kidney, unspecified kidney


N20.0 Calculus of kidney
Centers for Medicare & Medicaid Services (23 Oct. 2014). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.” Retrieved from


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