Uncomplicated labor with vaginal delivery at 38 weeks gestation. Liveborn single infant weighing 7 pounds, 8 ounces at birth. The delivering obstetrician has followed the patient throughout her pregnancy and will also be providing the post partum care for this patient. CPT Code(s): ICD-10-CM Code(s): ( there are 3 ICD codes)

Uncomplicated labor with vaginal delivery at 38 weeks gestation. Liveborn single infant weighing 7 pounds, 8 ounces at birth. The delivering obstetrician has followed the patient throughout her pregnancy and will also be providing the post partum care for this patient. CPT Code(s): ICD-10-CM Code(s): ( there are 3 ICD codes)

Essentials Health Info Management Principles/Practices

4th Edition

ISBN:9780357191651

Author:Bowie

Publisher:Bowie

Chapter6: Patient Record Documentation Guidelines: Inpatient, Outpatient, And Physician Office

Section6.5: Physician Office Record

Problem 3E

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CASE SCENARIO -DELIVERY ROOM Patient Susan is a 47 years old, G2P1 female who is living with her family at Silay City. She is a high school graduate, non-smoker, non-alcoholic and no allergies reported. Patient Susan was admitted to the labor room with the chief complaints of bright red profuse vaginal bleeding. She is in her third trimester of pregnancy, vaginal examination done by Dr .Torres revealed 5cm cervical dilatation with no labor pain .Dr. Torres ordered as follows; to start IVF of D5LR 1liter x 30gtts./min., O2inhalation @ 2 l/min via nasal cannula, Vital signs and FHB monitoring q 30mins. Put on bedrest. Patient Susan's vital signs upon admission: BP-90/60 mm/Hg    Temperature-37 degree Celsius PR-90 bpm     RR-30 cpm      FHB-130 bpm@ left lower quadrant. As a student nurse, based on the case scenario above: 1.What will be your impression about the condition of your patient? 2.What are the clinical…
CASE SCENARIO -DELIVERY ROOM Patient Susan is a 47 years old, G2P1 female who is living with her family at Silay City. She is a high school graduate, non-smoker, non-alcoholic and no allergies reported. Patient Susan was admitted to the labor room with the chief complaints of bright red profuse vaginal bleeding. She is in her third trimester of pregnancy, vaginal examination done by Dr .Torres revealed 5cm cervical dilatation with no labor pain .Dr. Torres ordered as follows; to start IVF of D5LR 1liter x 30gtts./min., O2inhalation @ 2 l/min via nasal cannula, Vital signs and FHB monitoring q 30mins. Put on bedrest. Patient Susan's vital signs upon admission: BP-90/60 mm/Hg    Temperature-37 degree Celsius PR-90 bpm     RR-30 cpm      FHB-130 bpm@ left lower quadrant. As a student nurse, based on the case scenario above: 1. Formulate 1 possible nursing diagnosis in the case scenario given( 1Actual/1Risk)
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