MEDICAL RECORD

Medical Record Section 1 – Initial database Date of Admission Date of discharge Age of patient Sex of patient Disposition 10/10/2022 10/15/2022 55 Male Home Identify chief complaint(s) – document all conditions that are mentioned and are relevant to current episode of care. WHY are they presenting for care? Admitting diagnoses Discharge diagnoses 1. Diabetic ulcer Diabetic ulcer 2. Uncontrolled diabetes Uncontrolled diabetes with peripheral circulatory disease, insulin dependent 3. Chronic renal failure Chronic renal failure 4. Pneumonia Pneumonia Anemia Review history of conditions and determine whether to code condition and/or Z code when applicable. (See Chapter 21.c.4 guideline) Conditions, symptoms, history, and associated codes Associated diagnoses and associated codes Relevant to current admission? Y or N Diabetic ulcer, Left heel E08.621 Y Chronic renal failure, ES N18.6 Y Coronary Artery Disease, CABG I25.702 N Diabetes, insulin dependence, Hyperglycemia E10.65 Y Myocardial infarction I25.2 N Long Term insulin dependent Z79.4 Y Peripheral vascular disease w/ knee amputation RT leg Pneumonia Anemia HYPERTENSION Coronary artery disease w/history of insulin dependences diabetes Acquired absence of right leg below knee S88011S J18.1 D64. 9 I10x E11.59 Z89.511 Y Y Y Y Y Y 1

Medical Record Review medication record : Identify medications being taken Identify conditions that the medications are managing Are conditions present on admission (POA) or AFTER admission? Identify whether being managed or getting worse? Floxin 400 mg POA M IV antibiotics Prevent infection AA M Paxil 10 mg AA M Lasix 80 mg AA M Cardizem CD 180 mg POA M Imdur 60 mg POA M Identify medications being taken Identify conditions that the medications are managing Are conditions present on admission (POA) or AFTER admission? Identify whether being managed or getting worse? 70/30 insulin POA M Nitrostat POA M If applicable, review Ambulance report to identify chief complaints. WHY patient is presenting for care. N/A If applicable, review ER report to identify chief complaints. WHY patient is present for care. A 55-year old male who was admitted through the ER for elevated blood sugars and necrotic heel ulcer of the left foot. The patient was admitted for control of his blood sugars and treatment of the heel ulcer. Section 2 – Diagnostic Reports (i.e., pathology, radiology) Diagnostic tests performed Conditions treated or justifies the test being done Identify whether condition(s) is/are ruled out or present and supports chief complaints Radiology Yes POA Comprehensive metabolic panel Yes POA CBC w/differential Yes Support chief complaint Microalbumin/creat urine Yes POA 2