HCS 216 Week 1 Nervous System – Analyzing a Progress Note

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HCS 216 Week 1 Nervous System – Analyzing a Progress Note
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Nervous 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 rehabilitation facility that specializes in neurological disorders.

 

Progress Note

 

History of Present Illness: Patient is a 22 y.o. female who was admitted to rehabilitation after an extended stay at University Hospital for treatment of a concussion with no loss of consciousness with subdural hematoma to the frontal lobe and a C1 cervical compression as the result of a motor vehicle accident. She has ongoing complaints of a frontal headache and signs of peripheral neuropathy. There does not appear to be any issue with her memory at this time. An EEG and EMG were performed prior to transfer. Her vital signs have been stable. The patient was admitted to the neurological rehabilitation floor for rehab treatment.

 

Plan: physical therapy evaluation, occupational therapy evaluation, and speech therapy evaluation.

 

Impression: concussion with no loss of consciousness, subdural hematoma, CI cervical closed fracture, peripheral neuropathy

 

Mark Jones Smith, MD

*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 in the Impression section of 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). An example has been provided for you.

 

Medical term
Medical code
Justification
Sources
Example: Concussion with no loss of consciousness
S06.0X0
There are a variety of codes to choose from, however, S06.0X0 was the code that detailed ‘with no loss of consciousness.’ This code was chosen because there was not enough detail provided to narrow it down to another code such as S06.0X1A (Concussion with loss of consciousness of 30 minutes or less.)
http://www.cdc.gov/nchs/icd/icd10cm.htm
Subdural hematoma

(Nontraumatic subdural hemorrhage, unspecified)

 
 
 
 
CI cervical closed fracture

(Unspecified displaced fracture of first cervical vertebra, initial encounter for closed fracture)
 
 
 
Peripheral neuropathy
 
 
 
 
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