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  • [Solved] WK4 QUESTION2 HP-216

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    COMPLETE WITH INSTRUCTIONS – ## WK4QUESTION2HP-216.docx **## WK4QUESTION2HP-216.docx** Note that the following question requires additional access to APC grouper software. Instructions: Provide the most correct responses. Question A 60-year-old female presented to the hospital outpatient surgical un…

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    – ## WK4QUESTION2HP-216.docx

    **## WK4QUESTION2HP-216.docx**

    Note that the following question requires additional access to APC grouper software.

    Instructions: Provide the most correct responses.

    Question

    A 60-year-old female presented to the hospital outpatient surgical unit for repair of an umbilical hernia, which was performed via an open approach in Operating Room B. The patient had minimal blood loss and was sent to the recovery room in good condition. The patient was discharged home later that same day.

    a. Assign the ICD-10-CM code(s) to the first-listed diagnosis. FILL IN BLANK WITH CODE

    b. Assign the CPT code(s) to the procedure(s). FILL IN BLANK WITH CODE

    c. Enter the patient's CPT procedure code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK WITH CODE

    A 55-year-old male presented to the hospital outpatient surgical unit for a cystoscopy. The patient's complaint was hematuria. A transurethral diagnostic cystoscopy was performed. No acute or abnormal findings were determined to be the cause of his hematuria. The patient was sent to the recovery room in good condition and was discharged later that same day.

    a. Assign the ICD-10-CM code(s) to the first-listed diagnosis. FILL IN BLANK WITH CODE

    b. Assign the CPT code(s) to the procedure(s). FILL IN BLANK CODE

    c. Enter the patient's CPT code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK CODE

    45-year-old female complained of fatigue and underwent a laboratory blood test that revealed elevated T3 and T4 levels. The patient underwent a fine-needle aspiration biopsy of her thyroid as an outpatient. The patient experienced minimal blood loss and was discharged home at the conclusion of the procedure.

    a. Assign the ICD-10-CM code(s) to the first-listed diagnosis and the additional diagnosis. FILL IN BLANK, FILL IN BLANK

    b. Assign the CPT code(s) to the procedure(s). FILL IN BLANK

    c. Enter the patient's CPT code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK

    An 80-year-old male patient presented to the hospital outpatient surgical unit for the removal of a cortical senile cataract from his left eye. The patient underwent an extracapsular cataract extraction with anterior chamber intraocular lens (IOL) implant insertion. There were no problems, and the patient was sent to the recovery room in good condition. He was later discharged home to be followed in the office.

    a. Assign the ICD-10-CM code(s) to the first-listed diagnosis. FILL IN BLANK

    b. Assign the CPT and HCPCS level II code(s) to the procedure(s). FILL IN BLANK

    c. Enter the patient's CPT and HCPCS level II code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK

    .

    Question

    A 67-year-old female underwent a laparoscopic cholecystectomy for cholelithiasis with acute cholecystitis. The patient also had an intraoperative cholangiogram performed. The patient had minimal blood loss and was discharged home later that day.

    a. Assign the ICD-10-CM code(s) to the first-listed diagnosis and the additional diagnoses. FILL IN BLANK

    b. Assign the CPT code(s) to the procedure(s). FILL IN BLANK

    c. Enter the patient's CPT procedure code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK

    A 75-year-old female patient is admitted directly to the hospital with the complaint of severe dyspnea. She has a history of hypertensive renal disease and diabetes mellitus controlled with insulin. Upon examination, she is noted to have edema on her legs and feet. Radiographic films indicate fluid in her lungs. Her albumin level is .5 grams per decaliter, and her creatinine level is 3.0 milligrams per decaliter. Sputum culture is positive for Klebsiella pneumoniae. Her blood pressure upon admission is 155/100. She is diagnosed with acute left ventricular heart failure, acute exacerbation of hypertensive renal disease, and pneumonia due to Klebsiella pneumoniae. Antihypertensive medications, antibiotics, insulin, Zocor, and intravenous diuretics are administered, and her diet is restricted for sodium and fluid. Three days later, she is discharged home in an improved condition.

    DISCHARGE DIAGNOSES: Acute left ventricular heart failure. Hypertensive heart and renal disease, stage 2. Pneumonia due to Klebsiella pneumoniae. Hyperlipidemia. Type 2 diabetes mellitus.

    a. Assign ICD-10-CM codes to the principal diagnosis of congestive heart failure and comorbidities.

    (No procedures were performed.)

    a. Principal diagnosis code: FILL IN BLANK

    b. Enter the patient’s age, gender, discharge status, and all applicable ICD-10-CM and ICD-10-PCS codes in the DRG grouper software. Review the DRG grouper results and answer the following questions:

    What is the MDC number? FILL IN BLANK

    c. What is the DRG number and description? FILL IN BLANK

    66-year-old man with a history of cerebrovascular accident who is seen in the emergency department for complaints of chest pain and oral phase dysphagia. He is noted to have a temperature of 101 degrees upon examination. He is admitted as a hospital inpatient for further evaluation and treatment. Has a history of type 2 diabetes mellitus and hypertension. Lab tests include a white blood cell count with differential and a chest X-ray. Results reveal that Mr. Browne has pneumonia, and a sputum culture is ordered. The sputum culture results are negative. A percutaneous endoscopic gastrostomy (PEG tube) is inserted to assist with his nutrition, which is difficult due to his dysphagia. He is administered respiratory therapy for the pneumonia. His feeding is done via the PEG tube. His oral antihypertensive and diabetic medications are continued as an inpatient. After several days he is discharged to a skilled nursing facility for further care.

    FINAL DIAGNOSES: Viral pneumonia. Oral phase dysphagia due to previous cerebrovascular accident

    (CVA). Type 2 diabetes mellitus. Hypertension.

    PROCEDURE: Insertion of percutaneous endoscopic gastrostomy (PEG tube).

    Question

    Assign the principal ICD-10-CM diagnosis code.FILL IN BLANK

    FINAL DIAGNOSES: Epistaxis. Acute posthemorrhagic anemia. Type 2 diabetes mellitus. Hypertension.

    Hyperlipidemia.

    PROCEDURES: Endoscopic control of right epistaxis with cautery. Transfusion with packed red blood cells.

    Question

    Assign the principal ICD-10-CM diagnosis code.FILL IN BLANK

    A 45-year-old female is admitted to the hospital with the chief complaint of severe left arm pain. This patient has a history of end stage renal failure, and she has an arteriovenous graft in her left arm for dialysis access. The patient's end stage renal failure is due to hypertensive renal disease. She receives dialysis on Tuesday, Thursday, and Saturday. The patient was seen, evaluated, and scheduled for surgery. Postoperative diagnosis was end stage renal failure with left upper extremity arteriovenous graft stenosis. Procedures performed are fluoroscopy of dialysis fistula (high osmolar), left upper extremity, and declotting of arteriovenous graft, left upper extremity with percutaneous infusion of urokinase. Postprocedurally, the patient had a run of sinus tachycardia that was treated with medication. Postprocedurally, her blood pressure was 163/100. She was administered intravenous antihypertensive medication for this. She was discharged on day two in an improved condition with instructions to follow up with her nephrologist at the renal clinic.

    FINAL DIAGNOSES: Severe left arm pain due to left upper extremity arteriovenous graft stenosis.

    Hypertensive renal disease with end stage renal failure. Postprocedural sinus tachycardia.

    PROCEDURES: Percutaneous declotting of arteriovenous graft, left upper extremity, with percutaneous infusion of urokinase. Fluoroscopy of dialysis fistula (high osmolar).

    a. Assign ICD-10-CM codes to the principal diagnosis. FILL IN BLANK

    b. Assign ICD-10-PCS codes to the principal procedure. FILL IN BLANK

    c. Enter the patient’s age, gender, discharge status, and all applicable ICD-10-CM and ICD-10-PCS codes in the DRG grouper software. Review the DRG grouper results and answer the following question:

    What is the DRG number? FILL IN BLANK

    FINAL DIAGNOSES: Aortic stenosis. Previous bypass graft surgery. Gout, right foot.

    PROCEDURES: Aortic valve replacement (open approach). Right and left cardiac catheterization (percutaneous approach).

    a. Assign ICD-10-CM codes to the principal diagnosis. FILL IN BLANK

    b. Assign ICD-10-PCS codes to the principal procedure. FILL IN BLANK

    c. Enter the patient’s age, gender, discharge status, and all applicable ICD-10-CM codes in the DRG grouper software. Review the DRG grouper results and answer the following question: What is the DRG number? FILL IN BLANK

    **## WK4QUESTION2HP-216.docx**

    Note that the following question requires additional access to APC grouper software.

    Instructions: Provide the most correct responses.

    Question

    A 60-year-old female presented to the hospital outpatient surgical unit for repair of an umbilical hernia, which was performed via an open approach in Operating Room B. The patient had minimal blood loss and was sent to the recovery room in good condition. The patient was discharged home later that same day.

    a. Assign the ICD-10-CM code(s) to the first-listed diagnosis. FILL IN BLANK WITH CODE

    b. Assign the CPT code(s) to the procedure(s). FILL IN BLANK WITH CODE

    c. Enter the patient's CPT procedure code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK WITH CODE

    A 55-year-old male presented to the hospital outpatient surgical unit for a cystoscopy. The patient's complaint was hematuria. A transurethral diagnostic cystoscopy was performed. No acute or abnormal findings were determined to be the cause of his hematuria. The patient was sent to the recovery room in good condition and was discharged later that same day.

    a. Assign the ICD-10-CM code(s) to the first-listed diagnosis. FILL IN BLANK WITH CODE

    b. Assign the CPT code(s) to the procedure(s). FILL IN BLANK CODE

    c. Enter the patient's CPT code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK CODE

    45-year-old female complained of fatigue and underwent a laboratory blood test that revealed elevated T3 and T4 levels. The patient underwent a fine-needle aspiration biopsy of her thyroid as an outpatient. The patient experienced minimal blood loss and was discharged home at the conclusion of the procedure.

    a. Assign the ICD-10-CM code(s) to the first-listed diagnosis and the additional diagnosis. FILL IN BLANK, FILL IN BLANK

    b. Assign the CPT code(s) to the procedure(s). FILL IN BLANK

    c. Enter the patient's CPT code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK

    An 80-year-old male patient presented to the hospital outpatient surgical unit for the removal of a cortical senile cataract from his left eye. The patient underwent an extracapsular cataract extraction with anterior chamber intraocular lens (IOL) implant insertion. There were no problems, and the patient was sent to the recovery room in good condition. He was later discharged home to be followed in the office.

    a. Assign the ICD-10-CM code(s) to the first-listed diagnosis. FILL IN BLANK

    b. Assign the CPT and HCPCS level II code(s) to the procedure(s). FILL IN BLANK

    c. Enter the patient's CPT and HCPCS level II code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK

    .

    Question

    A 67-year-old female underwent a laparoscopic cholecystectomy for cholelithiasis with acute cholecystitis. The patient also had an intraoperative cholangiogram performed. The patient had minimal blood loss and was discharged home later that day.

    a. Assign the ICD-10-CM code(s) to the first-listed diagnosis and the additional diagnoses. FILL IN BLANK

    b. Assign the CPT code(s) to the procedure(s). FILL IN BLANK

    c. Enter the patient's CPT procedure code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK

    A 75-year-old female patient is admitted directly to the hospital with the complaint of severe dyspnea. She has a history of hypertensive renal disease and diabetes mellitus controlled with insulin. Upon examination, she is noted to have edema on her legs and feet. Radiographic films indicate fluid in her lungs. Her albumin level is .5 grams per decaliter, and her creatinine level is 3.0 milligrams per decaliter. Sputum culture is positive for Klebsiella pneumoniae. Her blood pressure upon admission is 155/100. She is diagnosed with acute left ventricular heart failure, acute exacerbation of hypertensive renal disease, and pneumonia due to Klebsiella pneumoniae. Antihypertensive medications, antibiotics, insulin, Zocor, and intravenous diuretics are administered, and her diet is restricted for sodium and fluid. Three days later, she is discharged home in an improved condition.

    DISCHARGE DIAGNOSES: Acute left ventricular heart failure. Hypertensive heart and renal disease, stage 2. Pneumonia due to Klebsiella pneumoniae. Hyperlipidemia. Type 2 diabetes mellitus.

    a. Assign ICD-10-CM codes to the principal diagnosis of congestive heart failure and comorbidities.

    (No procedures were performed.)

    a. Principal diagnosis code: FILL IN BLANK

    b. Enter the patient’s age, gender, discharge status, and all applicable ICD-10-CM and ICD-10-PCS codes in the DRG grouper software. Review the DRG grouper results and answer the following questions:

    What is the MDC number? FILL IN BLANK

    c. What is the DRG number and description? FILL IN BLANK

    66-year-old man with a history of cerebrovascular accident who is seen in the emergency department for complaints of chest pain and oral phase dysphagia. He is noted to have a temperature of 101 degrees upon examination. He is admitted as a hospital inpatient for further evaluation and treatment. Has a history of type 2 diabetes mellitus and hypertension. Lab tests include a white blood cell count with differential and a chest X-ray. Results reveal that Mr. Browne has pneumonia, and a sputum culture is ordered. The sputum culture results are negative. A percutaneous endoscopic gastrostomy (PEG tube) is inserted to assist with his nutrition, which is difficult due to his dysphagia. He is administered respiratory therapy for the pneumonia. His feeding is done via the PEG tube. His oral antihypertensive and diabetic medications are continued as an inpatient. After several days he is discharged to a skilled nursing facility for further care.

    FINAL DIAGNOSES: Viral pneumonia. Oral phase dysphagia due to previous cerebrovascular accident

    (CVA). Type 2 diabetes mellitus. Hypertension.

    PROCEDURE: Insertion of percutaneous endoscopic gastrostomy (PEG tube).

    Question

    Assign the principal ICD-10-CM diagnosis code.FILL IN BLANK

    FINAL DIAGNOSES: Epistaxis. Acute posthemorrhagic anemia. Type 2 diabetes mellitus. Hypertension.

    Hyperlipidemia.

    PROCEDURES: Endoscopic control of right epistaxis with cautery. Transfusion with packed red blood cells.

    Question

    Assign the principal ICD-10-CM diagnosis code.FILL IN BLANK

    A 45-year-old female is admitted to the hospital with the chief complaint of severe left arm pain. This patient has a history of end stage renal failure, and she has an arteriovenous graft in her left arm for dialysis access. The patient's end stage renal failure is due to hypertensive renal disease. She receives dialysis on Tuesday, Thursday, and Saturday. The patient was seen, evaluated, and scheduled for surgery. Postoperative diagnosis was end stage renal failure with left upper extremity arteriovenous graft stenosis. Procedures performed are fluoroscopy of dialysis fistula (high osmolar), left upper extremity, and declotting of arteriovenous graft, left upper extremity with percutaneous infusion of urokinase. Postprocedurally, the patient had a run of sinus tachycardia that was treated with medication. Postprocedurally, her blood pressure was 163/100. She was administered intravenous antihypertensive medication for this. She was discharged on day two in an improved condition with instructions to follow up with her nephrologist at the renal clinic.

    FINAL DIAGNOSES: Severe left arm pain due to left upper extremity arteriovenous graft stenosis.

    Hypertensive renal disease with end stage renal failure. Postprocedural sinus tachycardia.

    PROCEDURES: Percutaneous declotting of arteriovenous graft, left upper extremity, with percutaneous infusion of urokinase. Fluoroscopy of dialysis fistula (high osmolar).

    a. Assign ICD-10-CM codes to the principal diagnosis. FILL IN BLANK

    b. Assign ICD-10-PCS codes to the principal procedure. FILL IN BLANK

    c. Enter the patient’s age, gender, discharge status, and all applicable ICD-10-CM and ICD-10-PCS codes in the DRG grouper software. Review the DRG grouper results and answer the following question:

    What is the DRG number? FILL IN BLANK

    FINAL DIAGNOSES: Aortic stenosis. Previous bypass graft surgery. Gout, right foot.

    PROCEDURES: Aortic valve replacement (open approach). Right and left cardiac catheterization (percutaneous approach).

    a. Assign ICD-10-CM codes to the principal diagnosis. FILL IN BLANK

    b. Assign ICD-10-PCS codes to the principal procedure. FILL IN BLANK

    c. Enter the patient’s age, gender, discharge status, and all applicable ICD-10-CM codes in the DRG grouper software. Review the DRG grouper results and answer the following question: What is the DRG number? FILL IN BLANK

  • [Solved] WK4 QUESTION3 HP-216

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    COMPLETE WITH INSTRUCTIONS – ## WK4QUESTION3HP-216.docx **## WK4QUESTION3HP-216.docx** WK4 QUESTION3 HP-216 Instructions: Provide the most correct response. Question One of the guidelines for effective physician queries is: Responses · Questions need not be supported by clinical findings · You may i…

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    – ## WK4QUESTION3HP-216.docx

    **## WK4QUESTION3HP-216.docx**

    WK4 QUESTION3 HP-216

    Instructions: Provide the most correct response.

    Question

    One of the guidelines for effective physician queries is:

    Responses

    · Questions need not be supported by clinical findings

    · You may introduce any new information not contained in the record

    · You can present the impact to reimbursement

    · Do not provide leading information

    Physician queries are acceptable in what format(s)?

    Responses

    · Multiple Choice

    · "Yes"/"No"

    · Open Ended

    ·
    All of these

    A patient is admitted from the ED with signs and symptoms of infection, including fever and elevated WBC. The admitting diagnosis is UTI with suspected sepsis. Possible sepsis is noted on the H&P and the infectious disease consult. Progress notes initially include "sepsis". The blood culture comes back negative, however, and following this, the diagnosis of sepsis continues to be documented on the progress notes as these are copied-and-pasted from day to day. The Discharge Summary documents "UTI—sepsis was ruled out".

    A physician query would be appropriate in this instance.

    Responses

    · True

    True

    ·
    False

    A patient develops anemia following a major surgery. The OR states that there was some bleeding; however, there were no additional procedures performed to control the bleeding that would not otherwise have been done. The patient was transfused, though, and serial H&Hs were followed throughout the remainder of the admission. Fluid overload also developed during the admission, around the same time as the patient was transfused. The final diagnosis on the Discharge Summary is simply "anemia". The body of the Discharge Summary attributes this to hemodilution from IV fluids.

    A physician query would be appropriate in this instance:

    Responses

    · True

    ·
    False

    Patient admitted with 5 days history of nausea and vomiting. Chest X-Ray indicates left upper lobe pneumonia. Antibiotics ordered.

    Proposed Query:

    Is the patient's pneumonia due to aspiration?

    Is this physician query appropriate, and, if not, why not?

    Responses

    · Appropriate

    · Not appropriate, contains a leading question

    · Not formatted correctly

    ·
    Appropriate with formatting for physician response

    Instructions: Provide the most correct response.

    Question

    Diagnosis of hypokalemia is documented in the progress note; labs indicate a potassium of 3.8

    Proposed Query:

    Please clarify the status of this diagnosis by documenting your response below

    ___ Hypokalemia was ruled out

    ___ Hypokalemia is valid diagnosis for this encounter

    ___ Hypokalemia was clinically insignificant finding

    ___ Unable to determine

    ___ Other (Please specify): ________________

    Is this query appropriate, and, if not, why not:

    Responses

    · Appropriate

    · Not appropriate, leading question

    · Not appropriate, as appropriate choices are not included

    Clinical indicators that were not included in the record were includedProstate mass is documented in the final discharge summary by the provider; however, the pathology report specifies prostate cancer.

    Is a query appropriate and, if not, why?

    Responses

    · Appropriate

    · Not appropriate, pathology report is always the definitive statement

    · Not appropriate, the final discharge diagnosis by the physician is the definitive statement

    ·
    Coding guidelines indicate when both diagnoses are listed, either may be assigned

    Wound care nurse states "new stage 3 pressure ulcer, right knee, not noted at time of admission to hospital"

    Would a physician query be appropriate in this instance, and, if not, why not?

    Responses

    · Appropriate

    · Not appropriate, clinical indicator has been provided appropriately

    · Not appropriate, as diagnosis given is appropriate to be coded

    ·
    Not appropriate, no additional information is needed for coding purposes

    Patient comes in with a fractured hip with plans to undergo a total hip replacement. At the time of CDI review, the physician has not documented any further specificity regarding the hip fracture. An X-ray was ordered for the right hip, and the radiology report describes the location of the fracture as intertrochanteric.

    Is a query for clarification of laterality and specific location of the fracture be constructed?

    Responses

    · Yes, the coder should always code to the highest level of specificity, so this information will be needed to do so.

    .

    · Yes, the radiology report cannot be utilized for capturing this information.

    · No, the radiology report cannot be used as the sole documentation, however, can be used to support coding to a greater level of specificity.

    · Yes, the coder should utilize the radiology report as the supporting clinical indicator for the query.

    Yes, the coder should utilize the radiology report as the supporting clinical indicator for the query.

    What essential elements should be included in a physician query?

    Responses

    · Diagnosis or condition that requires clarification listed where the information is found throughout the record

    · List of clinical indicators

    · How diagnosis needs to be further clarified

    ·
    All of the these

    **## WK4QUESTION3HP-216.docx**

    WK4 QUESTION3 HP-216

    Instructions: Provide the most correct response.

    Question

    One of the guidelines for effective physician queries is:

    Responses

    · Questions need not be supported by clinical findings

    · You may introduce any new information not contained in the record

    · You can present the impact to reimbursement

    · Do not provide leading information

    Physician queries are acceptable in what format(s)?

    Responses

    · Multiple Choice

    · "Yes"/"No"

    · Open Ended

    ·
    All of these

    A patient is admitted from the ED with signs and symptoms of infection, including fever and elevated WBC. The admitting diagnosis is UTI with suspected sepsis. Possible sepsis is noted on the H&P and the infectious disease consult. Progress notes initially include "sepsis". The blood culture comes back negative, however, and following this, the diagnosis of sepsis continues to be documented on the progress notes as these are copied-and-pasted from day to day. The Discharge Summary documents "UTI—sepsis was ruled out".

    A physician query would be appropriate in this instance.

    Responses

    · True

    True

    ·
    False

    A patient develops anemia following a major surgery. The OR states that there was some bleeding; however, there were no additional procedures performed to control the bleeding that would not otherwise have been done. The patient was transfused, though, and serial H&Hs were followed throughout the remainder of the admission. Fluid overload also developed during the admission, around the same time as the patient was transfused. The final diagnosis on the Discharge Summary is simply "anemia". The body of the Discharge Summary attributes this to hemodilution from IV fluids.

    A physician query would be appropriate in this instance:

    Responses

    · True

    ·
    False

    Patient admitted with 5 days history of nausea and vomiting. Chest X-Ray indicates left upper lobe pneumonia. Antibiotics ordered.

    Proposed Query:

    Is the patient's pneumonia due to aspiration?

    Is this physician query appropriate, and, if not, why not?

    Responses

    · Appropriate

    · Not appropriate, contains a leading question

    · Not formatted correctly

    ·
    Appropriate with formatting for physician response

    Instructions: Provide the most correct response.

    Question

    Diagnosis of hypokalemia is documented in the progress note; labs indicate a potassium of 3.8

    Proposed Query:

    Please clarify the status of this diagnosis by documenting your response below

    ___ Hypokalemia was ruled out

    ___ Hypokalemia is valid diagnosis for this encounter

    ___ Hypokalemia was clinically insignificant finding

    ___ Unable to determine

    ___ Other (Please specify): ________________

    Is this query appropriate, and, if not, why not:

    Responses

    · Appropriate

    · Not appropriate, leading question

    · Not appropriate, as appropriate choices are not included

    Clinical indicators that were not included in the record were includedProstate mass is documented in the final discharge summary by the provider; however, the pathology report specifies prostate cancer.

    Is a query appropriate and, if not, why?

    Responses

    · Appropriate

    · Not appropriate, pathology report is always the definitive statement

    · Not appropriate, the final discharge diagnosis by the physician is the definitive statement

    ·
    Coding guidelines indicate when both diagnoses are listed, either may be assigned

    Wound care nurse states "new stage 3 pressure ulcer, right knee, not noted at time of admission to hospital"

    Would a physician query be appropriate in this instance, and, if not, why not?

    Responses

    · Appropriate

    · Not appropriate, clinical indicator has been provided appropriately

    · Not appropriate, as diagnosis given is appropriate to be coded

    ·
    Not appropriate, no additional information is needed for coding purposes

    Patient comes in with a fractured hip with plans to undergo a total hip replacement. At the time of CDI review, the physician has not documented any further specificity regarding the hip fracture. An X-ray was ordered for the right hip, and the radiology report describes the location of the fracture as intertrochanteric.

    Is a query for clarification of laterality and specific location of the fracture be constructed?

    Responses

    · Yes, the coder should always code to the highest level of specificity, so this information will be needed to do so.

    .

    · Yes, the radiology report cannot be utilized for capturing this information.

    · No, the radiology report cannot be used as the sole documentation, however, can be used to support coding to a greater level of specificity.

    · Yes, the coder should utilize the radiology report as the supporting clinical indicator for the query.

    Yes, the coder should utilize the radiology report as the supporting clinical indicator for the query.

    What essential elements should be included in a physician query?

    Responses

    · Diagnosis or condition that requires clarification listed where the information is found throughout the record

    · List of clinical indicators

    · How diagnosis needs to be further clarified

    ·
    All of the these

  • [Solved] WK4 QUESTION4 HP-216

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    Executive Solution Overview

    COMPLETE WITH INSTRUCTIONS – ## WK4QUESTION4HP-216.docx **## WK4QUESTION4HP-216.docx** WK4 QUESTION4 HP-216 Services performed in the office setting where a non-physician provider performs a service under direct physician supervision when all requirements are met are referred to as Responses · split…

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    COMPLETE WITH INSTRUCTIONS

    – ## WK4QUESTION4HP-216.docx

    **## WK4QUESTION4HP-216.docx**

    WK4 QUESTION4 HP-216

    Services performed in the office setting where a non-physician provider performs a service under direct physician supervision when all requirements are met are referred to as

    Responses

    · split/shared services.

    .

    · incident to.

    .

    · assistant surgeon.

    ·
    supervised services.

    Services performed in this department within the hospital are available 24 hours a day and provide unscheduled episodic services for patients needing immediate medical attention.

    Responses

    · Outpatient surgery

    · Outpatient clinic

    · Observation

    ·
    Emergency Department

    Provider-based or Hospital-based facility services are defined as:

    Responses

    · Supplied by a provider outside the hospital venue.

    .

    · Supplied by a provider located in the outpatient area of the hospital.

    .

    · Supplied by a provider located in the ancillary area of the hospital.

    ·
    Supplied by a provider owned and operated by a facility or hospital.

    Assistant surgeon charges are appropriate in what instances?

    Responses

    · when the assistant surgeon is medically indicated

    · when the name of the assistant surgeon is listed in the operative report

    · when documentation that details what the assistant surgeon contributed to the case is present

    ·
    all of these

    Services provided in the teaching facility are reimbursable when:

    Responses

    · furnished by a resident when the teaching physician is present during critical or key portions of the service.

    · never reimbursable in the hospital setting.

    · statement of "seen, agree with plan" are documented by the physician.

    .

    ·
    services are performed and documented by a medical student.

    Split/shared services are reimbursable when:

    Responses

    · both the physician and non-physician “share” the services and the billable provider performed a substantive portion of the MDM or greater than half the total time spent as of 2024.

    .

    · the non-physician performs the service without the need for a physician to assist in providing the service.

    · performed in the office setting.

    ·
    a minimum of 20 minutes is documented.

    What is the authoritative source for reporting procedures/services performed by the physician?

    Responses

    · CPT Assistant

    · HCPCS Coding Clinic

    · Coding Clinic

    ·
    ICD-10 Official Guidelines for Coding and Reporting

    What is the authoritative source for reporting facility procedures/services?

    Responses

    · Merck's Manual

    · HCPCS Coding Clinic

    · CPT Assistant

    ·
    Coding Clinic

    What claim form is utilized for reporting physician services?

    Responses

    · Explanation of Benefits

    · CMS 1500

    · Ambulatory Payment Classifications

    ·
    CMS 1450

    What is the name of the reimbursement system utilized for categorizing payments for outpatient facility services?

    Responses

    · Payment status indicators

    · MS-DRGs

    · Ambulatory Payment Classifications

    ·
    Diagnosed Related Groups

    **## WK4QUESTION4HP-216.docx**

    WK4 QUESTION4 HP-216

    Services performed in the office setting where a non-physician provider performs a service under direct physician supervision when all requirements are met are referred to as

    Responses

    · split/shared services.

    .

    · incident to.

    .

    · assistant surgeon.

    ·
    supervised services.

    Services performed in this department within the hospital are available 24 hours a day and provide unscheduled episodic services for patients needing immediate medical attention.

    Responses

    · Outpatient surgery

    · Outpatient clinic

    · Observation

    ·
    Emergency Department

    Provider-based or Hospital-based facility services are defined as:

    Responses

    · Supplied by a provider outside the hospital venue.

    .

    · Supplied by a provider located in the outpatient area of the hospital.

    .

    · Supplied by a provider located in the ancillary area of the hospital.

    ·
    Supplied by a provider owned and operated by a facility or hospital.

    Assistant surgeon charges are appropriate in what instances?

    Responses

    · when the assistant surgeon is medically indicated

    · when the name of the assistant surgeon is listed in the operative report

    · when documentation that details what the assistant surgeon contributed to the case is present

    ·
    all of these

    Services provided in the teaching facility are reimbursable when:

    Responses

    · furnished by a resident when the teaching physician is present during critical or key portions of the service.

    · never reimbursable in the hospital setting.

    · statement of "seen, agree with plan" are documented by the physician.

    .

    ·
    services are performed and documented by a medical student.

    Split/shared services are reimbursable when:

    Responses

    · both the physician and non-physician “share” the services and the billable provider performed a substantive portion of the MDM or greater than half the total time spent as of 2024.

    .

    · the non-physician performs the service without the need for a physician to assist in providing the service.

    · performed in the office setting.

    ·
    a minimum of 20 minutes is documented.

    What is the authoritative source for reporting procedures/services performed by the physician?

    Responses

    · CPT Assistant

    · HCPCS Coding Clinic

    · Coding Clinic

    ·
    ICD-10 Official Guidelines for Coding and Reporting

    What is the authoritative source for reporting facility procedures/services?

    Responses

    · Merck's Manual

    · HCPCS Coding Clinic

    · CPT Assistant

    ·
    Coding Clinic

    What claim form is utilized for reporting physician services?

    Responses

    · Explanation of Benefits

    · CMS 1500

    · Ambulatory Payment Classifications

    ·
    CMS 1450

    What is the name of the reimbursement system utilized for categorizing payments for outpatient facility services?

    Responses

    · Payment status indicators

    · MS-DRGs

    · Ambulatory Payment Classifications

    ·
    Diagnosed Related Groups

  • [Solved] 1 soap note

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    – ## NU610Unit1CaseStudyrevisedMarch2024_12417624.PDF – ## SOAPNoteTemplate-Final1_12417645.PDF **## NU610Unit1CaseStudyrevisedMarch2024_12417624.PDF** 1 NU610 Unit 1 Case Study A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had them since she was…

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    – ## NU610Unit1CaseStudyrevisedMarch2024_12417624.PDF

    – ## SOAPNoteTemplate-Final1_12417645.PDF

    **## NU610Unit1CaseStudyrevisedMarch2024_12417624.PDF**

    1

    NU610 Unit 1 Case Study

    A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had

    them since she was a teenager, but they have become more debilitating recently. The episodes occur

    once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the

    right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing

    sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain

    including loud noises and movement. She has taken several over the counter medication like naproxen

    and acetaminophen for the pain but the only thing that makes it better is going to sleep in a dark quiet

    room. Reports no drug allergies but has seasonal and allergies to pet dander. A thorough history reveals

    a freshman in college. Denies alcohol, illicit drug and tobacco use. Last health visit was over the

    Summer, up to date on health maintenance for her age. She denies fever, chills, night sweats or neck

    stiffness. She denies visual changes other than photophobia. She denies chest pain, palpitations,

    shortness of breath or cough. She denies abdominal pain, has some nausea with the headaches but no

    vomiting. Denies numbness, tingling, weakness or changes in mood. Vital signs: temperature 98.5, BP

    112/70, HR 62, RR 17, 99% RA, Ht. 68 inches, Wt. 151 lbs. Alert and oriented to self, place, time and

    situation. Appears stated age with skin warm and dry. Normocephalic, PERRL, TM gray with adequate

    conf of light bilaterally, no tenderness over sinuses. Mucous membranes pink and dry. No palpable

    masses, adenopathy or thyroid enlargement. Regular heart rate and rhythm without murmurs. No

    edema. Lungs clear bilaterally, no use of accessory muscles. Soft, non-tender, non-distended abdomen

    with normoactive bowel sounds. Normal visual acuity using Snellen chart 20/20, face symmetrical with

    symmetrical smile and puffing out cheeks. Weber and Rinne test performed with normal bone and air

    conduction. Palate and uvula at rest are free of fasciculations and symmetry noted at test and when pt.

    says “ah.” Positive gag reflex. Shrug shoulders spontaneously and against resistance, hypoglossal nerve

    intact. Muscle tone inspected, palpated without atrophy and strength 5/5. Bicep, patellar and Achilles

    reflexes 2+ bilaterally with negative Babinski. Able to distinguish light and deep touch. Able to

    complete heel to shin, gait steady.

    **## SOAPNoteTemplate-Final1_12417645.PDF**

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    S: SUBJECTIVE DATA
    CC: What are they being seen for? This is the reason that the patient sought

    care, stated in their own words/words of their caregiver, or paraphrased.

    HPI: Use the “OLDCART” approach for collecting data and documenting

    findings. [O=onset, L=location, D=duration, C=characteristics,

    A=associated/aggravating factors, R=relieving factors, T=treatment,

    S=summary]

    PMH: This should include past illness/diagnosis, conditions, traumas,

    hospitalizations, and surgical history. Include dates if possible.

    ALLERGIES State the offending medication/food and the reactions.

    MEDICATIONS Names, dosages, and routes of administration along with indication of

    use.

    SH Related to the problem, educational level/literacy, smoking, alcohol,

    drugs, HIV risk, sexually active, caffeine, work and other stressors.

    Cultural and spiritual beliefs that impact health and illness. Financial

    resources.

    FH Use terms like maternal, paternal, and the diseases along with the ages

    they were deceased or diagnosed if known.

    HEALTH

    PROMOTION &

    MAINTENANCE

    Required for all SOAP notes: Immunizations, exercise, diet, etc.

    Remember to use the United States Clinical Preventative Services Task

    Force (USPSTF) for age-appropriate indicators. This should reflect what

    the patient is presently doing regarding the guidelines. Other wellness

    visits including but not limited to dental and eye exams.

    ROS

    (put N/A in sections

    not completed day of

    exam)

    Constitutional

    Head

    Eyes

    Ears, Nose, Mouth, Throat
    Neck
    Cardiovascular/Peripheral

    Vascular

    Respiratory

    Breast

    Gastrointestinal

    [https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations)

    [https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations)

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    Genitourinary
    Musculoskeletal

    Integumentary

    Neurological

    Psychiatric (screening tools: Ex:

    PHQ-9, MMSE, GAD-7)

    Endocrine

    Hematologic/Lymphatic
    Allergic/Immunologic

    Other

    O: OBJECTIVE DATA
    VITALS: HR: RR: BP: Temp:

    SpO2%: Ht: Wt: BMI:

    Age: LMP: PAIN:

    PHYSICAL

    EXAM

    (Pertinent data

    related to

    presenting

    problem or

    visit type. Put

    N/A in sections

    not completed

    day of exam)

    General Appearance

    Head

    Eyes

    ENT, Mouth
    Neck
    Cardiovascular/Peripheral Vascular

    Respiratory

    Breast

    Gastrointestinal
    Genitourinary Male

    • External Exam

    • Internal Exam

    Genitourinary Female

    • External Exam

    • Internal Exam

    Musculoskeletal

    Integumentary

    Neurological

    Psychiatric

    Endocrine

    Hematologic/Lymphatic

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    Allergic/Immunologic

    Other

    A: ASSESSMENT AND DIAGNOSIS
    DIAGNOSIS ICD-10 CODES

    PRIORITIZE
    DIAGNOSIS

    1.

    2.

    3.

    VISIT CODES CPT BILLING CODES

    DIAGNOSTICS

    POC TESTING

    TESTS REVIEWED

    P: PLAN
    ACTIONS 1. Diagnosis:

    Diagnostics Order: labs, diagnostics testing (tests that you planned

    for/ordered during the encounter that you plan to review/evaluate

    relative to your work up for the patient’s chief complaint.)

    Therapeutic: changes in meds, skin care, counseling, include full

    prescribing information for any pharmacologic interventions

    including quantity and number of refills for any new or refilled

    medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no

    refills)

    Education: information clients need in order to address their health

    problems. Include follow-up care. Anticipatory guidance and

    counseling.

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    Consultation/Collaboration: referrals or consult while in clinic with

    another provider. If no referral made was there a possible referral

    you could make and why? Advance care planning.

    2. Diagnosis:

    Diagnostics Order:

    Therapeutic:

    Education:

    Consultation/Collaboration:

    3. Diagnosis:

    Diagnostics Order:

    Therapeutic:

    Education:

    Consultation/Collaboration:

    PREVENTITIVE

    (Used for

    comprehensive exams)

    Enter Guidance, Health Promotion, and/or Disease Prevention for

    patient, family, and/or caregiver.

    FOLLOW UP

    **## SOAPNoteTemplate-Final1_12417645.PDF**

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    S: SUBJECTIVE DATA
    CC: What are they being seen for? This is the reason that the patient sought

    care, stated in their own words/words of their caregiver, or paraphrased.

    HPI: Use the “OLDCART” approach for collecting data and documenting

    findings. [O=onset, L=location, D=duration, C=characteristics,

    A=associated/aggravating factors, R=relieving factors, T=treatment,

    S=summary]

    PMH: This should include past illness/diagnosis, conditions, traumas,

    hospitalizations, and surgical history. Include dates if possible.

    ALLERGIES State the offending medication/food and the reactions.

    MEDICATIONS Names, dosages, and routes of administration along with indication of

    use.

    SH Related to the problem, educational level/literacy, smoking, alcohol,

    drugs, HIV risk, sexually active, caffeine, work and other stressors.

    Cultural and spiritual beliefs that impact health and illness. Financial

    resources.

    FH Use terms like maternal, paternal, and the diseases along with the ages

    they were deceased or diagnosed if known.

    HEALTH

    PROMOTION &

    MAINTENANCE

    Required for all SOAP notes: Immunizations, exercise, diet, etc.

    Remember to use the United States Clinical Preventative Services Task

    Force (USPSTF) for age-appropriate indicators. This should reflect what

    the patient is presently doing regarding the guidelines. Other wellness

    visits including but not limited to dental and eye exams.

    ROS

    (put N/A in sections

    not completed day of

    exam)

    Constitutional

    Head

    Eyes

    Ears, Nose, Mouth, Throat
    Neck
    Cardiovascular/Peripheral

    Vascular

    Respiratory

    Breast

    Gastrointestinal

    [https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations)

    [https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations)

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    Genitourinary
    Musculoskeletal

    Integumentary

    Neurological

    Psychiatric (screening tools: Ex:

    PHQ-9, MMSE, GAD-7)

    Endocrine

    Hematologic/Lymphatic
    Allergic/Immunologic

    Other

    O: OBJECTIVE DATA
    VITALS: HR: RR: BP: Temp:

    SpO2%: Ht: Wt: BMI:

    Age: LMP: PAIN:

    PHYSICAL

    EXAM

    (Pertinent data

    related to

    presenting

    problem or

    visit type. Put

    N/A in sections

    not completed

    day of exam)

    General Appearance

    Head

    Eyes

    ENT, Mouth
    Neck
    Cardiovascular/Peripheral Vascular

    Respiratory

    Breast

    Gastrointestinal
    Genitourinary Male

    • External Exam

    • Internal Exam

    Genitourinary Female

    • External Exam

    • Internal Exam

    Musculoskeletal

    Integumentary

    Neurological

    Psychiatric

    Endocrine

    Hematologic/Lymphatic

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    Allergic/Immunologic

    Other

    A: ASSESSMENT AND DIAGNOSIS
    DIAGNOSIS ICD-10 CODES

    PRIORITIZE
    DIAGNOSIS

    1.

    2.

    3.

    VISIT CODES CPT BILLING CODES

    DIAGNOSTICS

    POC TESTING

    TESTS REVIEWED

    P: PLAN
    ACTIONS 1. Diagnosis:

    Diagnostics Order: labs, diagnostics testing (tests that you planned

    for/ordered during the encounter that you plan to review/evaluate

    relative to your work up for the patient’s chief complaint.)

    Therapeutic: changes in meds, skin care, counseling, include full

    prescribing information for any pharmacologic interventions

    including quantity and number of refills for any new or refilled

    medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no

    refills)

    Education: information clients need in order to address their health

    problems. Include follow-up care. Anticipatory guidance and

    counseling.

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    Consultation/Collaboration: referrals or consult while in clinic with

    another provider. If no referral made was there a possible referral

    you could make and why? Advance care planning.

    2. Diagnosis:

    Diagnostics Order:

    Therapeutic:

    Education:

    Consultation/Collaboration:

    3. Diagnosis:

    Diagnostics Order:

    Therapeutic:

    Education:

    Consultation/Collaboration:

    PREVENTITIVE

    (Used for

    comprehensive exams)

    Enter Guidance, Health Promotion, and/or Disease Prevention for

    patient, family, and/or caregiver.

    FOLLOW UP

    **## NU610Unit1CaseStudyrevisedMarch2024_12417624.PDF**

    1

    NU610 Unit 1 Case Study

    A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had

    them since she was a teenager, but they have become more debilitating recently. The episodes occur

    once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the

    right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing

    sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain

    including loud noises and movement. She has taken several over the counter medication like naproxen

    and acetaminophen for the pain but the only thing that makes it better is going to sleep in a dark quiet

    room. Reports no drug allergies but has seasonal and allergies to pet dander. A thorough history reveals

    a freshman in college. Denies alcohol, illicit drug and tobacco use. Last health visit was over the

    Summer, up to date on health maintenance for her age. She denies fever, chills, night sweats or neck

    stiffness. She denies visual changes other than photophobia. She denies chest pain, palpitations,

    shortness of breath or cough. She denies abdominal pain, has some nausea with the headaches but no

    vomiting. Denies numbness, tingling, weakness or changes in mood. Vital signs: temperature 98.5, BP

    112/70, HR 62, RR 17, 99% RA, Ht. 68 inches, Wt. 151 lbs. Alert and oriented to self, place, time and

    situation. Appears stated age with skin warm and dry. Normocephalic, PERRL, TM gray with adequate

    conf of light bilaterally, no tenderness over sinuses. Mucous membranes pink and dry. No palpable

    masses, adenopathy or thyroid enlargement. Regular heart rate and rhythm without murmurs. No

    edema. Lungs clear bilaterally, no use of accessory muscles. Soft, non-tender, non-distended abdomen

    with normoactive bowel sounds. Normal visual acuity using Snellen chart 20/20, face symmetrical with

    symmetrical smile and puffing out cheeks. Weber and Rinne test performed with normal bone and air

    conduction. Palate and uvula at rest are free of fasciculations and symmetry noted at test and when pt.

    says “ah.” Positive gag reflex. Shrug shoulders spontaneously and against resistance, hypoglossal nerve

    intact. Muscle tone inspected, palpated without atrophy and strength 5/5. Bicep, patellar and Achilles

    reflexes 2+ bilaterally with negative Babinski. Able to distinguish light and deep touch. Able to

    complete heel to shin, gait steady.

    **## SOAPNoteTemplate-Final1_12417645.PDF**

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    S: SUBJECTIVE DATA
    CC: What are they being seen for? This is the reason that the patient sought

    care, stated in their own words/words of their caregiver, or paraphrased.

    HPI: Use the “OLDCART” approach for collecting data and documenting

    findings. [O=onset, L=location, D=duration, C=characteristics,

    A=associated/aggravating factors, R=relieving factors, T=treatment,

    S=summary]

    PMH: This should include past illness/diagnosis, conditions, traumas,

    hospitalizations, and surgical history. Include dates if possible.

    ALLERGIES State the offending medication/food and the reactions.

    MEDICATIONS Names, dosages, and routes of administration along with indication of

    use.

    SH Related to the problem, educational level/literacy, smoking, alcohol,

    drugs, HIV risk, sexually active, caffeine, work and other stressors.

    Cultural and spiritual beliefs that impact health and illness. Financial

    resources.

    FH Use terms like maternal, paternal, and the diseases along with the ages

    they were deceased or diagnosed if known.

    HEALTH

    PROMOTION &

    MAINTENANCE

    Required for all SOAP notes: Immunizations, exercise, diet, etc.

    Remember to use the United States Clinical Preventative Services Task

    Force (USPSTF) for age-appropriate indicators. This should reflect what

    the patient is presently doing regarding the guidelines. Other wellness

    visits including but not limited to dental and eye exams.

    ROS

    (put N/A in sections

    not completed day of

    exam)

    Constitutional

    Head

    Eyes

    Ears, Nose, Mouth, Throat
    Neck
    Cardiovascular/Peripheral

    Vascular

    Respiratory

    Breast

    Gastrointestinal

    [https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations)

    [https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations)

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    Genitourinary
    Musculoskeletal

    Integumentary

    Neurological

    Psychiatric (screening tools: Ex:

    PHQ-9, MMSE, GAD-7)

    Endocrine

    Hematologic/Lymphatic
    Allergic/Immunologic

    Other

    O: OBJECTIVE DATA
    VITALS: HR: RR: BP: Temp:

    SpO2%: Ht: Wt: BMI:

    Age: LMP: PAIN:

    PHYSICAL

    EXAM

    (Pertinent data

    related to

    presenting

    problem or

    visit type. Put

    N/A in sections

    not completed

    day of exam)

    General Appearance

    Head

    Eyes

    ENT, Mouth
    Neck
    Cardiovascular/Peripheral Vascular

    Respiratory

    Breast

    Gastrointestinal
    Genitourinary Male

    • External Exam

    • Internal Exam

    Genitourinary Female

    • External Exam

    • Internal Exam

    Musculoskeletal

    Integumentary

    Neurological

    Psychiatric

    Endocrine

    Hematologic/Lymphatic

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    Allergic/Immunologic

    Other

    A: ASSESSMENT AND DIAGNOSIS
    DIAGNOSIS ICD-10 CODES

    PRIORITIZE
    DIAGNOSIS

    1.

    2.

    3.

    VISIT CODES CPT BILLING CODES

    DIAGNOSTICS

    POC TESTING

    TESTS REVIEWED

    P: PLAN
    ACTIONS 1. Diagnosis:

    Diagnostics Order: labs, diagnostics testing (tests that you planned

    for/ordered during the encounter that you plan to review/evaluate

    relative to your work up for the patient’s chief complaint.)

    Therapeutic: changes in meds, skin care, counseling, include full

    prescribing information for any pharmacologic interventions

    including quantity and number of refills for any new or refilled

    medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no

    refills)

    Education: information clients need in order to address their health

    problems. Include follow-up care. Anticipatory guidance and

    counseling.

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    Consultation/Collaboration: referrals or consult while in clinic with

    another provider. If no referral made was there a possible referral

    you could make and why? Advance care planning.

    2. Diagnosis:

    Diagnostics Order:

    Therapeutic:

    Education:

    Consultation/Collaboration:

    3. Diagnosis:

    Diagnostics Order:

    Therapeutic:

    Education:

    Consultation/Collaboration:

    PREVENTITIVE

    (Used for

    comprehensive exams)

    Enter Guidance, Health Promotion, and/or Disease Prevention for

    patient, family, and/or caregiver.

    FOLLOW UP

    **## NU610Unit1CaseStudyrevisedMarch2024_12417624.PDF**

    1

    NU610 Unit 1 Case Study

    A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had

    them since she was a teenager, but they have become more debilitating recently. The episodes occur

    once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the

    right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing

    sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain

    including loud noises and movement. She has taken several over the counter medication like naproxen

    and acetaminophen for the pain but the only thing that makes it better is going to sleep in a dark quiet

    room. Reports no drug allergies but has seasonal and allergies to pet dander. A thorough history reveals

    a freshman in college. Denies alcohol, illicit drug and tobacco use. Last health visit was over the

    Summer, up to date on health maintenance for her age. She denies fever, chills, night sweats or neck

    stiffness. She denies visual changes other than photophobia. She denies chest pain, palpitations,

    shortness of breath or cough. She denies abdominal pain, has some nausea with the headaches but no

    vomiting. Denies numbness, tingling, weakness or changes in mood. Vital signs: temperature 98.5, BP

    112/70, HR 62, RR 17, 99% RA, Ht. 68 inches, Wt. 151 lbs. Alert and oriented to self, place, time and

    situation. Appears stated age with skin warm and dry. Normocephalic, PERRL, TM gray with adequate

    conf of light bilaterally, no tenderness over sinuses. Mucous membranes pink and dry. No palpable

    masses, adenopathy or thyroid enlargement. Regular heart rate and rhythm without murmurs. No

    edema. Lungs clear bilaterally, no use of accessory muscles. Soft, non-tender, non-distended abdomen

    with normoactive bowel sounds. Normal visual acuity using Snellen chart 20/20, face symmetrical with

    symmetrical smile and puffing out cheeks. Weber and Rinne test performed with normal bone and air

    conduction. Palate and uvula at rest are free of fasciculations and symmetry noted at test and when pt.

    says “ah.” Positive gag reflex. Shrug shoulders spontaneously and against resistance, hypoglossal nerve

    intact. Muscle tone inspected, palpated without atrophy and strength 5/5. Bicep, patellar and Achilles

    reflexes 2+ bilaterally with negative Babinski. Able to distinguish light and deep touch. Able to

    complete heel to shin, gait steady.

    **## SOAPNoteTemplate-Final1_12417645.PDF**

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    S: SUBJECTIVE DATA
    CC: What are they being seen for? This is the reason that the patient sought

    care, stated in their own words/words of their caregiver, or paraphrased.

    HPI: Use the “OLDCART” approach for collecting data and documenting

    findings. [O=onset, L=location, D=duration, C=characteristics,

    A=associated/aggravating factors, R=relieving factors, T=treatment,

    S=summary]

    PMH: This should include past illness/diagnosis, conditions, traumas,

    hospitalizations, and surgical history. Include dates if possible.

    ALLERGIES State the offending medication/food and the reactions.

    MEDICATIONS Names, dosages, and routes of administration along with indication of

    use.

    SH Related to the problem, educational level/literacy, smoking, alcohol,

    drugs, HIV risk, sexually active, caffeine, work and other stressors.

    Cultural and spiritual beliefs that impact health and illness. Financial

    resources.

    FH Use terms like maternal, paternal, and the diseases along with the ages

    they were deceased or diagnosed if known.

    HEALTH

    PROMOTION &

    MAINTENANCE

    Required for all SOAP notes: Immunizations, exercise, diet, etc.

    Remember to use the United States Clinical Preventative Services Task

    Force (USPSTF) for age-appropriate indicators. This should reflect what

    the patient is presently doing regarding the guidelines. Other wellness

    visits including but not limited to dental and eye exams.

    ROS

    (put N/A in sections

    not completed day of

    exam)

    Constitutional

    Head

    Eyes

    Ears, Nose, Mouth, Throat
    Neck
    Cardiovascular/Peripheral

    Vascular

    Respiratory

    Breast

    Gastrointestinal

    [https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations)

    [https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations)

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    Genitourinary
    Musculoskeletal

    Integumentary

    Neurological

    Psychiatric (screening tools: Ex:

    PHQ-9, MMSE, GAD-7)

    Endocrine

    Hematologic/Lymphatic
    Allergic/Immunologic

    Other

    O: OBJECTIVE DATA
    VITALS: HR: RR: BP: Temp:

    SpO2%: Ht: Wt: BMI:

    Age: LMP: PAIN:

    PHYSICAL

    EXAM

    (Pertinent data

    related to

    presenting

    problem or

    visit type. Put

    N/A in sections

    not completed

    day of exam)

    General Appearance

    Head

    Eyes

    ENT, Mouth
    Neck
    Cardiovascular/Peripheral Vascular

    Respiratory

    Breast

    Gastrointestinal
    Genitourinary Male

    • External Exam

    • Internal Exam

    Genitourinary Female

    • External Exam

    • Internal Exam

    Musculoskeletal

    Integumentary

    Neurological

    Psychiatric

    Endocrine

    Hematologic/Lymphatic

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    Allergic/Immunologic

    Other

    A: ASSESSMENT AND DIAGNOSIS
    DIAGNOSIS ICD-10 CODES

    PRIORITIZE
    DIAGNOSIS

    1.

    2.

    3.

    VISIT CODES CPT BILLING CODES

    DIAGNOSTICS

    POC TESTING

    TESTS REVIEWED

    P: PLAN
    ACTIONS 1. Diagnosis:

    Diagnostics Order: labs, diagnostics testing (tests that you planned

    for/ordered during the encounter that you plan to review/evaluate

    relative to your work up for the patient’s chief complaint.)

    Therapeutic: changes in meds, skin care, counseling, include full

    prescribing information for any pharmacologic interventions

    including quantity and number of refills for any new or refilled

    medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no

    refills)

    Education: information clients need in order to address their health

    problems. Include follow-up care. Anticipatory guidance and

    counseling.

    SOAP Note _______
    NU___:_________

    Herzing University

    Name:_________________________
    Typhon Encounter #: _____________________

    Comprehensive:____Focused:____

    Consultation/Collaboration: referrals or consult while in clinic with

    another provider. If no referral made was there a possible referral

    you could make and why? Advance care planning.

    2. Diagnosis:

    Diagnostics Order:

    Therapeutic:

    Education:

    Consultation/Collaboration:

    3. Diagnosis:

    Diagnostics Order:

    Therapeutic:

    Education:

    Consultation/Collaboration:

    PREVENTITIVE

    (Used for

    comprehensive exams)

    Enter Guidance, Health Promotion, and/or Disease Prevention for

    patient, family, and/or caregiver.

    FOLLOW UP

    – 1
    – 2

  • [Solved] Asssigment

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    – ## Week1assignment.docx **## Week1assignment.docx** **Week 1 assignment** Completion requirements **Opened:** Monday, September 1, 2025, 12:00 AM **Due:** Saturday, September 6, 2025, 11:59 PM Define cultural competence. Explain the importance of Cultural competence in our profession. Provide exam…

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    – ## Week1assignment.docx

    **## Week1assignment.docx**

    **Week 1 assignment**

    Completion requirements

    **Opened:** Monday, September 1, 2025, 12:00 AM

    **Due:** Saturday, September 6, 2025, 11:59 PM

    Define cultural competence. Explain the importance of Cultural competence in our profession. Provide examples

    Rubric: 3 pages

    – 5 pages maximum including title page and references

    -APA format including references

    -At Leat 3 references not older than 5 years

    Due date: Sunday 9/6/2025 at 11:59 pm

    **General Structure of an APA Essay**

    An APA-formatted essay typically includes the following sections:

    1.
    **Title Page**

    2.
    **Abstract** (optional)

    3.
    **Main Body**

    · Introduction

    · Method (if applicable)

    · Results (if applicable)

    · Discussion

    · Conclusion

    4.
    **References not older than 5 years**

    5.
    **Turnitin no more than 20% AI no more than 20%**

    **## Week1assignment.docx**

    **Week 1 assignment**

    Completion requirements

    **Opened:** Monday, September 1, 2025, 12:00 AM

    **Due:** Saturday, September 6, 2025, 11:59 PM

    Define cultural competence. Explain the importance of Cultural competence in our profession. Provide examples

    Rubric: 3 pages

    – 5 pages maximum including title page and references

    -APA format including references

    -At Leat 3 references not older than 5 years

    Due date: Sunday 9/6/2025 at 11:59 pm

    **General Structure of an APA Essay**

    An APA-formatted essay typically includes the following sections:

    1.
    **Title Page**

    2.
    **Abstract** (optional)

    3.
    **Main Body**

    · Introduction

    · Method (if applicable)

    · Results (if applicable)

    · Discussion

    · Conclusion

    4.
    **References not older than 5 years**

    5.
    **Turnitin no more than 20% AI no more than 20%**

  • [Solved] Nursing HOMEWORK

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    – ## WEEK2PRAC6675Practicum_Experience_Plan3.docx **## WEEK2PRAC6675Practicum_Experience_Plan3.docx** **Master of Science in Nursing** **Practicum Experience Plan** **Overview:** Your Practicum experience includes working in a clinical setting that will help you gain the knowledge and skills nee…

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    – ## WEEK2PRAC6675Practicum_Experience_Plan3.docx

    **## WEEK2PRAC6675Practicum_Experience_Plan3.docx**

    **Master of Science in Nursing**

    **Practicum Experience Plan**

    **Overview:**

    Your Practicum experience includes working in a clinical setting that will help you gain the knowledge and skills needed as an advanced practice nurse. In your practicum experience, you will develop a practicum plan that sets forth objectives to frame and guide your practicum experience.

    As part of your Practicum Experience Plan, you will not only plan for your learning in your practicum experience but also work through various patient visits with focused notes as well as one (1) journal entry.

    **Complete each section below.**

    **Part 1: Quarter/Term/Year and Contact Information**

    **_Section A_**

    **Quarter/Term/Year:**

    **Student** **Contact Information**

    Name:

    Street Address:

    City, State, Zip:

    Home Phone:

    Work Phone:

    Cell Phone:

    Fax:

    E-mail:

    **Preceptor** **Contact Information**

    Name:

    Organization:

    Street Address:

    City, State, Zip:

    Work Phone:

    Cell Phone:

    Fax:

    Professional/Work E-mail:

    **Part 2: Individualized Practicum Learning Objectives**

    Refer to the instructions in Week 2 to create individualized practicum learning objectives that meet the requirements for this course. These objectives should be aligned specifically to your Practicum experience. Your objectives should address your self-assessment of the skills found in the “PMHNP Clinical Skills Self-Assessment Form” you completed in Week 1.

    As you develop your individualized practicum learning objective, be sure to write them using the SMART format. Use the resources found in Week 2 to guide your development. Once you review your resources, continue and complete the following.
    **Note**: Please make sure each of your objectives are connected to your self-assessment. Also, consider that you will need to demonstrate how you are advancing your knowledge in the clinical specialty.

    \*\* YOU MUST HAVE 3 NEW OBJECTIVES EACH QUARTER. You may include previous practicum objectives; however, you still must have 3 new objectives for your current course.

    **Objective 1:** <write your objective here> (
    **_Note_**: this objective should relate to a specific skill you would like to improve from your self-assessment)

    **Planned Activities:**

    **Mode of Assessment:**(Note: Verification will be documented in Meditrek)

    **PRAC Course Outcome(s) Addressed:**

    · (for example) Develop professional plans in advanced nursing practice for the practicum experience

    · (for example) Assess advanced practice nursing skills for strengths and opportunities

    **Objective 2:** <write your objective here> (
    **_Note_**: this objective should relate to a specific skill you would like to improve from your self-assessment)

    **Planned Activities:**

    **Mode of Assessment:**(Note: Verification will be documented in Meditrek)

    **PRAC Course Outcome(s) Addressed:**

    ·

    **Objective 3:** <write your objective here> (
    **_Note_**: this objective should relate to a specific skill you would like to improve from your self-assessment)

    **Planned Activities:**

    **Mode of Assessment:**(Note: Verification will be documented in Meditrek)

    **PRAC Course Outcome(s) Addressed:**

    ·

    **Part 3: Projected Timeline/Schedule**

    Estimate how many hours you expect to work on your Practicum each week. *
    **Note**: All of your hours and activities must be supervised by your Preceptor and completed onsite. Your Preceptor will approve all hours, but your activities will be approved by both your Preceptor and Instructor. Any changes to this plan must be approved.

    This timeline is intended as a planning tool; your actual schedule may differ from the projections you are making now.

    _I intend to complete the 144 or 160 Practicum hours (as applicable) according to the following timeline/schedule. I also understand that I must see at least 80 patients during my practicum experience. I understand that I may not complete my practicum hours sooner than 8 weeks. I understand I may not be in the practicum setting longer than 8 hours per day unless pre-approved by my faculty._

    | | | | |
    | — | — | — | — |
    | | **Number of Clinical Hours Projected for Week (hours you are in Practicum Setting at your Field Site)** | **Number of Weekly Hours for Professional Development (these are not practicum hour)** | **Number of Weekly Hours for Practicum Coursework (these are not practicum hours)** |
    | **Week 1** | | | |
    | **Week 2** | | | |
    | **Week 3** | | | |
    | **Week 4** | | | |
    | **Week 5** | | | |
    | **Week 6** | | | |
    | **Week 7** | | | |
    | **Week 8** | | | |
    | **Week 9** | | | |
    | **Week 10** | | | |
    | **Week 11** | | | |
    | **Total Hours** (must meet the following requirements) | 144 or 160 Hours | | |

    **Part 4 – Signatures**

    **Student Signature (electronic): Date:**

    **Practicum Faculty Signature (electronic)**: Date:**

    \*\* Faculty signature signifies approval of Practicum Experience Plan (PEP)

    Submit your Practicum Experience Plan
    **on or before Day 7** of
    **Week 2** for faculty review and approval.

    Once approved, you will receive a copy of the PEP for your records. You must share an approved copy with your Preceptor. The Preceptor is not required to sign this form.

    © 2020 Walden University 3

    **## WEEK2PRAC6675Practicum_Experience_Plan3.docx**

    **Master of Science in Nursing**

    **Practicum Experience Plan**

    **Overview:**

    Your Practicum experience includes working in a clinical setting that will help you gain the knowledge and skills needed as an advanced practice nurse. In your practicum experience, you will develop a practicum plan that sets forth objectives to frame and guide your practicum experience.

    As part of your Practicum Experience Plan, you will not only plan for your learning in your practicum experience but also work through various patient visits with focused notes as well as one (1) journal entry.

    **Complete each section below.**

    **Part 1: Quarter/Term/Year and Contact Information**

    **_Section A_**

    **Quarter/Term/Year:**

    **Student** **Contact Information**

    Name:

    Street Address:

    City, State, Zip:

    Home Phone:

    Work Phone:

    Cell Phone:

    Fax:

    E-mail:

    **Preceptor** **Contact Information**

    Name:

    Organization:

    Street Address:

    City, State, Zip:

    Work Phone:

    Cell Phone:

    Fax:

    Professional/Work E-mail:

    **Part 2: Individualized Practicum Learning Objectives**

    Refer to the instructions in Week 2 to create individualized practicum learning objectives that meet the requirements for this course. These objectives should be aligned specifically to your Practicum experience. Your objectives should address your self-assessment of the skills found in the “PMHNP Clinical Skills Self-Assessment Form” you completed in Week 1.

    As you develop your individualized practicum learning objective, be sure to write them using the SMART format. Use the resources found in Week 2 to guide your development. Once you review your resources, continue and complete the following.
    **Note**: Please make sure each of your objectives are connected to your self-assessment. Also, consider that you will need to demonstrate how you are advancing your knowledge in the clinical specialty.

    \*\* YOU MUST HAVE 3 NEW OBJECTIVES EACH QUARTER. You may include previous practicum objectives; however, you still must have 3 new objectives for your current course.

    **Objective 1:** <write your objective here> (
    **_Note_**: this objective should relate to a specific skill you would like to improve from your self-assessment)

    **Planned Activities:**

    **Mode of Assessment:**(Note: Verification will be documented in Meditrek)

    **PRAC Course Outcome(s) Addressed:**

    · (for example) Develop professional plans in advanced nursing practice for the practicum experience

    · (for example) Assess advanced practice nursing skills for strengths and opportunities

    **Objective 2:** <write your objective here> (
    **_Note_**: this objective should relate to a specific skill you would like to improve from your self-assessment)

    **Planned Activities:**

    **Mode of Assessment:**(Note: Verification will be documented in Meditrek)

    **PRAC Course Outcome(s) Addressed:**

    ·

    **Objective 3:** <write your objective here> (
    **_Note_**: this objective should relate to a specific skill you would like to improve from your self-assessment)

    **Planned Activities:**

    **Mode of Assessment:**(Note: Verification will be documented in Meditrek)

    **PRAC Course Outcome(s) Addressed:**

    ·

    **Part 3: Projected Timeline/Schedule**

    Estimate how many hours you expect to work on your Practicum each week. *
    **Note**: All of your hours and activities must be supervised by your Preceptor and completed onsite. Your Preceptor will approve all hours, but your activities will be approved by both your Preceptor and Instructor. Any changes to this plan must be approved.

    This timeline is intended as a planning tool; your actual schedule may differ from the projections you are making now.

    _I intend to complete the 144 or 160 Practicum hours (as applicable) according to the following timeline/schedule. I also understand that I must see at least 80 patients during my practicum experience. I understand that I may not complete my practicum hours sooner than 8 weeks. I understand I may not be in the practicum setting longer than 8 hours per day unless pre-approved by my faculty._

    | | | | |
    | — | — | — | — |
    | | **Number of Clinical Hours Projected for Week (hours you are in Practicum Setting at your Field Site)** | **Number of Weekly Hours for Professional Development (these are not practicum hour)** | **Number of Weekly Hours for Practicum Coursework (these are not practicum hours)** |
    | **Week 1** | | | |
    | **Week 2** | | | |
    | **Week 3** | | | |
    | **Week 4** | | | |
    | **Week 5** | | | |
    | **Week 6** | | | |
    | **Week 7** | | | |
    | **Week 8** | | | |
    | **Week 9** | | | |
    | **Week 10** | | | |
    | **Week 11** | | | |
    | **Total Hours** (must meet the following requirements) | 144 or 160 Hours | | |

    **Part 4 – Signatures**

    **Student Signature (electronic): Date:**

    **Practicum Faculty Signature (electronic)**: Date:**

    \*\* Faculty signature signifies approval of Practicum Experience Plan (PEP)

    Submit your Practicum Experience Plan
    **on or before Day 7** of
    **Week 2** for faculty review and approval.

    Once approved, you will receive a copy of the PEP for your records. You must share an approved copy with your Preceptor. The Preceptor is not required to sign this form.

    © 2020 Walden University 3

  • [Solved] WK4 DISCUSSION1 HP-216

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    COMPLETE WITH 250 WORDS – ## WK4DISCUSSION1HP-216.docx **## WK4DISCUSSION1HP-216.docx** WK4 DISCUSSION1 HP-216 **Upholding PHI During Difficult Situations** Your best friend tells you that they have started to date a wonderful person. When introduced, you immediately recognize that they are a patien…

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    COMPLETE WITH 250 WORDS

    – ## WK4DISCUSSION1HP-216.docx

    **## WK4DISCUSSION1HP-216.docx**

    WK4 DISCUSSION1 HP-216

    **Upholding PHI During Difficult Situations**

    Your best friend tells you that they have started to date a wonderful person. When introduced, you immediately recognize that they are a patient in the medical practice that you currently work at. This person has a long history of drug and alcohol abuse and is currently receiving treatment by one of your physicians’. The patient has also been previously arrested for driving under the influence.

    Demonstrate how you would handle the above patient PHI situation with your best friend.

    Include the following aspects in the discussion:

    · Outline what information (if any) you can disclose to your best friend?

    · Would it be appropriate for you to speak to the patient directly about their medical history since they are seeing your best friend?

    · Discuss if there is anything that you may be able to say to your best friend without acknowledging that they are a patient.

    · Discuss if you feel this would be a challenging situation to be in and if you feel HIPAA Is too strict?

    HIPAA Compliance

    In this week's focus on HIPAA compliance, consider the role it plays in healthcare interactions. How do you perceive the importance of understanding and implementing appropriate interactions with patients when explaining insurance information under the guidelines of HIPAA? Share your insights on the challenges and considerations involved in maintaining patient privacy and confidentiality while communicating effectively. Engage with your classmates to exchange thoughts on how cultural awareness and sensitivity further contribute to ensuring compliance with HIPAA regulations in diverse healthcare settings.

    **## WK4DISCUSSION1HP-216.docx**

    WK4 DISCUSSION1 HP-216

    **Upholding PHI During Difficult Situations**

    Your best friend tells you that they have started to date a wonderful person. When introduced, you immediately recognize that they are a patient in the medical practice that you currently work at. This person has a long history of drug and alcohol abuse and is currently receiving treatment by one of your physicians’. The patient has also been previously arrested for driving under the influence.

    Demonstrate how you would handle the above patient PHI situation with your best friend.

    Include the following aspects in the discussion:

    · Outline what information (if any) you can disclose to your best friend?

    · Would it be appropriate for you to speak to the patient directly about their medical history since they are seeing your best friend?

    · Discuss if there is anything that you may be able to say to your best friend without acknowledging that they are a patient.

    · Discuss if you feel this would be a challenging situation to be in and if you feel HIPAA Is too strict?

    HIPAA Compliance

    In this week's focus on HIPAA compliance, consider the role it plays in healthcare interactions. How do you perceive the importance of understanding and implementing appropriate interactions with patients when explaining insurance information under the guidelines of HIPAA? Share your insights on the challenges and considerations involved in maintaining patient privacy and confidentiality while communicating effectively. Engage with your classmates to exchange thoughts on how cultural awareness and sensitivity further contribute to ensuring compliance with HIPAA regulations in diverse healthcare settings.

  • [Solved] The Role of the Nurse Informaticist in Systems Development and Implementation

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    **To Prepare:** – Review the steps of the Systems Development Life Cycle (SDLC) and reflect on the scenario presented. – Consider the benefits and challenges associated with involving a nurse leader on an implementation team for health information technology. **The Assignment: (2 pages not including…

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    **To Prepare:**
    – Review the steps of the Systems Development Life Cycle (SDLC) and reflect on the scenario presented.
    – Consider the benefits and challenges associated with involving a nurse leader on an implementation team for health information technology.
    **The Assignment: (2 pages not including the title and reference page)**
    In preparation of filling this role, develop a 2 page role description for a graduate-level nurse to guide his/her participation on the implementation team. The role description should be based on the SDLC stages and tasks and should clearly define how this individual will participate in and impact each of the following steps:
    – Planning and requirements definition
    – Analysis
    – Design of the new system
    – Implementation
    – Post-implementation support
    – Use APA format and include a title page and reference page.
    – Use the Turnitin Drafts to check your match percentage before submitting your work.

  • [Solved] catherine owens

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    In-depth study guidance and analytical solution covering catherine owens.

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    Assignment Prompt & Instructions

    Full assignment prompt and step-by-step guidance are included in the downloadable solution file.

  • [Solved] Nursing NEED ASSIGNMENT BY 9/10/2025. PLEASE NO PLAGARISM

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    CHECK ATTACHMENT FOR INSTRUCTIONS – ## PRESENTATIONWEEK9.docx **## PRESENTATIONWEEK9.docx** Within the ACNM Division of Education is the Midwifery student and new graduate section, dedicated to meeting the needs of students and new graduates. Please explore the [ACNM websiteLinks to an external site…

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    CHECK ATTACHMENT FOR INSTRUCTIONS

    – ## PRESENTATIONWEEK9.docx

    **## PRESENTATIONWEEK9.docx**

    Within the ACNM Division of Education is the Midwifery student and new graduate section, dedicated to meeting the needs of students and new graduates. Please explore the
    [ACNM websiteLinks to an external site.](https://www.midwife.org/) and view the You are ACNM presentation below.  After you have viewed the presentation, please write a 2-3 page essay in APA format
    _._ You should address the following questions in your report.

    presentation link:

    https://youtu.be/I0CZc_e0N4Y

    1. Describe the organizational structure of ACNM.

    2. What is your reflection on the six elements of the ACNM strategic plan?

    3. Which committee would you like to join and why?

    4. Who is your affiliate leader?

    5. What region is your state in?

    6. Who is your region representative?

    7. Are you familiar with any legislative action that your affiliate is working on?

    8. What are your plans to attend a local meeting in the future?

    9. What did you enjoy most about the "
    _You are ACNM"_ presentation?

    10. Include the following preclinical information:

    · Your RCF's name

    · Your clinical advisor's same

    · The date you sent your resume to your RCF

    · The apps or advice your RCF gave about creating your pocket brain.

    **## PRESENTATIONWEEK9.docx**

    Within the ACNM Division of Education is the Midwifery student and new graduate section, dedicated to meeting the needs of students and new graduates. Please explore the
    [ACNM websiteLinks to an external site.](https://www.midwife.org/) and view the You are ACNM presentation below.  After you have viewed the presentation, please write a 2-3 page essay in APA format
    _._ You should address the following questions in your report.

    presentation link:

    https://youtu.be/I0CZc_e0N4Y

    1. Describe the organizational structure of ACNM.

    2. What is your reflection on the six elements of the ACNM strategic plan?

    3. Which committee would you like to join and why?

    4. Who is your affiliate leader?

    5. What region is your state in?

    6. Who is your region representative?

    7. Are you familiar with any legislative action that your affiliate is working on?

    8. What are your plans to attend a local meeting in the future?

    9. What did you enjoy most about the "
    _You are ACNM"_ presentation?

    10. Include the following preclinical information:

    · Your RCF's name

    · Your clinical advisor's same

    · The date you sent your resume to your RCF

    · The apps or advice your RCF gave about creating your pocket brain.