C. Intake Domain 13. This patient was started on an enteral feeding postoperatively. Why do you think this decision was made? 14. What type of enteral formula is Vital HN? Is it an appropriate choice for this patient? 15. Why was the enteral formula started at 25 cc/hr?

Understanding Health Insurance: A Guide to Billing and Reimbursement
14th Edition
ISBN:9781337679480
Author:GREEN
Publisher:GREEN
Chapter8: Hcpcs Level Ii Coding
Section: Chapter Questions
Problem 11R
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Question
UHU
UNIVERSITY HOSPITAL
BED #
1
DATE:
8/30
TIME:
1700
ADMISSION DATABASE
Yellow
PRIMARY PERSON TO CONTACT:
Name: Maria Rodriguez
DOB: 12/19
(age 38)
Physician: A. Gustaf, MD
☐ Green ☐White
Name: Emilio Santiago (brother)
TRIAGE STATUS (ER ONLY):
☐ Red
Initial Vital Signs
Home #: 555-212-7890
TEMP:
102
RESP:
32
SAO2:
HT (in):
WT (lb): 110
5'2"
UBW 145
B/P:
78/60
PULSE:
68
LAST TETANUS
5 years ago
LAST ATE
yesterday
LAST DRANK
water 1 hour ago
Work #: 555-213-4563
ORIENTATION TO UNIT: ☑Call light ☑Television/telephone
☑Bathroom ☑Visiting ☑ Smoking ☑Meals
☑Patient rights/responsibilities
CHIEF COMPLAINT/HX OF PRESENT ILLNESS
"I found out I had an ulcer 2 weeks ago. Last night I seemed to have
gotten worse. I have been vomiting, and I have diarrhea. My pain is
terrible. I think I have blood in my vomit and my diarrhea."
ALLERGIES: Meds, Food, IVP Dye, Seafood: Type of Reaction
Codeine causes nausea and vomiting.
PREVIOUS HOSPITALIZATIONS/SURGERIES
For delivery of her two daughters only
PERSONAL ARTICLES: (Check if retained/describe)
☐ Contacts ☐ R ☐ L
☑Jewelry: wedding band
☐ Other:
VALUABLES ENVELOPE:
Valuables instructions
☐ Dentures ☐ Upper ☐ Lower
INFORMATION OBTAINED FROM:
☑ Patient
☑Family
☐ Previous record
☐ Responsible party
Maria Rodriquez
Home Medications (including OTC)
Medication
bismuth subsalicylate
metronidazole
tetracycline
omeprazole
Signature
Codes: A Sent home
Dose
B=Sent to pharmacy
Frequency
Time of Last Dose
Code
C=Not brought in
Patient Understanding of Drug
525 mg
4 x daily
this AM
C
yes
250 mg
4 x daily
this AM
C
yes
500 mg
4 x daily
this AM
C
yes
20 mg
2 x daily
this AM
C
yes
Do you take all medications as prescribed?
☑ Yes
☐ No If no, why?
PATIENT/FAMILY HISTORY
☐ Cold in past two weeks
☐ Hay fever
☐ Emphysema/lung problems
TB disease/positive TB skin test
☐ Cancer
☐ Stroke/past paralysis
Heart attack
☐ Angina/chest pain
☐ Heart problems
RISK SCREENING
Have you had a blood transfusion?
☐ Yes
☑ No
☑ Yes ☐ No
☐ High blood pressure
☐ Arthritis
Claustrophobia
Circulation problems
Easy bleeding/bruising/anemia
Sickle cell disease
☐ Liver disease/jaundice
☐ Thyroid disease
☑ Diabetes Maternal grandmother
☐ Kidney/urinary problems
☑ Gastric/abdominal pain/heartburn Patient
Hearing problems
Glaucoma/eye problems
Back pain
☐ Seizures
☑ Other Father and grandfather had
ulcer disease
FOR WOMEN Ages 12-52
Do you smoke?
Is there any chance you could be pregnant?
☐ Yes
☑ No
If yes, how often?
If yes, how many pack(s)? 1.5/day for 15 years
Does anyone in your household smoke? ☑ Yes ☐ No
Do you drink alcohol? ☐ Yes
When was your last drink?
If yes, expected date (EDC):
Gravida/Para: 2/2
☑ No
ALL WOMEN
How much?
Do
you take any recreational drugs?
Yes
☑ No
Date of last Pap smear: Feb. of this year
Do you perform regular breast self-exams?
☑ Yes
☐ No
If yes, type:
Route:
ALL MEN
Frequency:
Date last used:
Do you perform regular testicular exams?
☐ Yes
☐ No
Additional comments:
× Sophia MaMillan, t
Signature/Title
Transcribed Image Text:UHU UNIVERSITY HOSPITAL BED # 1 DATE: 8/30 TIME: 1700 ADMISSION DATABASE Yellow PRIMARY PERSON TO CONTACT: Name: Maria Rodriguez DOB: 12/19 (age 38) Physician: A. Gustaf, MD ☐ Green ☐White Name: Emilio Santiago (brother) TRIAGE STATUS (ER ONLY): ☐ Red Initial Vital Signs Home #: 555-212-7890 TEMP: 102 RESP: 32 SAO2: HT (in): WT (lb): 110 5'2" UBW 145 B/P: 78/60 PULSE: 68 LAST TETANUS 5 years ago LAST ATE yesterday LAST DRANK water 1 hour ago Work #: 555-213-4563 ORIENTATION TO UNIT: ☑Call light ☑Television/telephone ☑Bathroom ☑Visiting ☑ Smoking ☑Meals ☑Patient rights/responsibilities CHIEF COMPLAINT/HX OF PRESENT ILLNESS "I found out I had an ulcer 2 weeks ago. Last night I seemed to have gotten worse. I have been vomiting, and I have diarrhea. My pain is terrible. I think I have blood in my vomit and my diarrhea." ALLERGIES: Meds, Food, IVP Dye, Seafood: Type of Reaction Codeine causes nausea and vomiting. PREVIOUS HOSPITALIZATIONS/SURGERIES For delivery of her two daughters only PERSONAL ARTICLES: (Check if retained/describe) ☐ Contacts ☐ R ☐ L ☑Jewelry: wedding band ☐ Other: VALUABLES ENVELOPE: Valuables instructions ☐ Dentures ☐ Upper ☐ Lower INFORMATION OBTAINED FROM: ☑ Patient ☑Family ☐ Previous record ☐ Responsible party Maria Rodriquez Home Medications (including OTC) Medication bismuth subsalicylate metronidazole tetracycline omeprazole Signature Codes: A Sent home Dose B=Sent to pharmacy Frequency Time of Last Dose Code C=Not brought in Patient Understanding of Drug 525 mg 4 x daily this AM C yes 250 mg 4 x daily this AM C yes 500 mg 4 x daily this AM C yes 20 mg 2 x daily this AM C yes Do you take all medications as prescribed? ☑ Yes ☐ No If no, why? PATIENT/FAMILY HISTORY ☐ Cold in past two weeks ☐ Hay fever ☐ Emphysema/lung problems TB disease/positive TB skin test ☐ Cancer ☐ Stroke/past paralysis Heart attack ☐ Angina/chest pain ☐ Heart problems RISK SCREENING Have you had a blood transfusion? ☐ Yes ☑ No ☑ Yes ☐ No ☐ High blood pressure ☐ Arthritis Claustrophobia Circulation problems Easy bleeding/bruising/anemia Sickle cell disease ☐ Liver disease/jaundice ☐ Thyroid disease ☑ Diabetes Maternal grandmother ☐ Kidney/urinary problems ☑ Gastric/abdominal pain/heartburn Patient Hearing problems Glaucoma/eye problems Back pain ☐ Seizures ☑ Other Father and grandfather had ulcer disease FOR WOMEN Ages 12-52 Do you smoke? Is there any chance you could be pregnant? ☐ Yes ☑ No If yes, how often? If yes, how many pack(s)? 1.5/day for 15 years Does anyone in your household smoke? ☑ Yes ☐ No Do you drink alcohol? ☐ Yes When was your last drink? If yes, expected date (EDC): Gravida/Para: 2/2 ☑ No ALL WOMEN How much? Do you take any recreational drugs? Yes ☑ No Date of last Pap smear: Feb. of this year Do you perform regular breast self-exams? ☑ Yes ☐ No If yes, type: Route: ALL MEN Frequency: Date last used: Do you perform regular testicular exams? ☐ Yes ☐ No Additional comments: × Sophia MaMillan, t Signature/Title
C. Intake Domain
13. This patient was started on an enteral feeding postoperatively. Why do you think this
decision was made?
14. What type of enteral formula is Vital HN? Is it an appropriate choice for this patient?
15. Why was the enteral formula started at 25 cc/hr?
Transcribed Image Text:C. Intake Domain 13. This patient was started on an enteral feeding postoperatively. Why do you think this decision was made? 14. What type of enteral formula is Vital HN? Is it an appropriate choice for this patient? 15. Why was the enteral formula started at 25 cc/hr?
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