Patient is visiting aunt and was brought into the ER and was mini-altered. Patient was given Geodon and Haldol to calm him and EKG was done. EKG showed A. fib with heart rate as high as 170. He was put on Cardizem drip and admitted for further evaluation. The patient denies symptoms of any chest pain, fever, nausea or vomiting.
The inpatient coder ensures that the data entered is relevant, indicating the reason that the patient was admitted, which involves the kind of illness and a breakdown of the treatment that was given (Henderson.) The inpatient coder uses the current version of ICD-CM classification for the most appropriate DRG assignment for assigning codes to diagnoses and procedures. They have to be able to determine the correct diagnosis and secondary diagnosis, identifying and assigning co-morbidities and complications and principle procedure codes. The inpatient coder is also responsible for selecting the proper DRG and Discharge Disposition Code. The impatient coder sends the documentation to HIM Operations for follow-up when Physicians documentation is not clear or straight forward.
* Assess patient’s pain level and administers appropriate pain relief measures. * Maintains patient’s safety(airway, circulation, prevention of injury) * Administer medication, fluid and blood component therapy, if prescribed. * Assess patient’s readiness for transfer to in hospital unit or for discharge home based on institutional policy. 2. Identify priority nursing care to prevent potential complications following this type of surgery.
PERIOPERATIVE CASE STUDY Student Name _April Jones______________ Date ___02-01-2014__________ I. PREOPERATIVE PHASE A. Client profile: 52 y.o. Caucasian female 68in 200 lbs B. Current Medical Diagnosis/surgical event: Chronic bilateral otitis media (intermittent infections), left posterior perforation(left ear drum hole) , Eustachian tube dysfunction, moderate bilateral conductive hearing loss C. Support system: patient’s fiancé: no labs ordered, none in chart D. Selected Preoperative Assessment 1. Previous Hospitalizations: none listed 2.
Movie Write up Samantha Viken November 9, 2014 In what way was the care and support provided by Dr. Posner and Dr. Kelekian ultimately inadequate for Vivian Bearing? The support and care provided by Dr. Posner and Dr. Kelekian was inadequate because Vivian Bearing was not treated as a person. In the film when Vivian first was diagnosed by Dr. Kelekian she was not shown any moral support for her diagnosis. When Vivian went in to have her first chemo treatment she was treated with no compaction by Dr. Posner. This went on throughout the film.
The patient made it very clear that she did not want the phlebotomist to draw her blood (Finnegan, 2013).This same phlebotomist has drawn her for several days for a Prothrombin Time (PT) and Activated Thromboplastic Time (aPTT) without incident, so he reports this situation to the nurse. The nurse informs the phlebotomist that the patient has formed a complaint against him and did not want him, in particular, to draw her blood. The blood had been drawn from the dorsal side of her hand for several days, which was now bruised and swollen. The patient complained of moderate pain, especially when she moved her fingers. Upon observation there was a diffuse ecchymosis over the dorsal side of the hand that extends up the forearm to the elbow.
Compliance Management Tanya L. Thomas Western Governors University Abstract In this paper I will define compliance from a management perspective. I will address problems with compliance as it relates to healthcare. I will analyze specific problem with healthcare compliance. I will give scenarios of what circumstances can come from non-compliance. I will outline a prevention plan and discuss how to stay compliant.
Mrs T suffers from Headaches and is prescribed medication for this on an ‘as and when required basis’. Mrs T is alert and aware when she has headaches and will express her need for this medication independently. Although Mrs T can express her immediate needs her Dementia has affected her long and short term memory. Mrs T does not have capacity and an assessment has been completed. It had been reported to the Manager by a member of staff that she had witnessed another member of staff speaking to Mrs T inappropriately and had refused to give Mrs T medication which she had requested for her headaches and had concerns regarding this conduct.
The nursing staff reported that her chest infection had resolved and she was now more alert. They did get her out of bed but with lot of difficulty, as she would not follow any instructions or commands. The first time I saw her I had the rehab assistant with me. We were going to assess her ability to walk. I together with the rehab assistant tried to get her to walk, but we were not able to convince her to even stand from sitting in the chair.
Correct Answer(s): C and EKat is seen by the healthcare provider, who recommends osteoporosis screening since Kat is at risk for osteoporosis. The nurse meets with Kat to provide client teaching.