1. Anesthesia administered to a normal, healthy patient underg
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1. Anesthesia administered to a normal, healthy patient undergoing an esophageal procedure is coded as A. 00500-P1. B. 00502-P1. C. 00500-P2. D. 00506-P1. 2. A new patient comes into the doctor's office for her annual gynecological exam. During the course of the exam, she undergoes a screening cervical cytopathology smear, which is performed by an automated system under the supervision of a physician. What HCPCS code is assigned? A. G0185 B. G7869 C. G7452 D. G0147 3. A new patient is seen for a home visit that involves a comprehensive history, examination, and medical decision making of high complexity. What code should be assigned? A. 99349 B. 99345 C. 99342 D. 99350 4. A prolonged evaluation and management service before and/or after direct patient care for one hour is coded as A. 99359. B. 99358. C. 99361. D. 99360. 5. A 57-year-old patient is admitted to the hospital for a hip arthroscopy procedure. The patient is a normal healthy patient with no systemic disease. What anesthesia CPT code should be assigned? A. 01242-P2 B. 01202-P1 C. 01202-P3 D. 01202-P5 6. Anesthesia for procedures performed on the larynx and trachea in an 11-month-old child would be assigned to code A. 00620. B. 00625. C. 00326. D. 00532. 7. A patient returns for a follow-up office visit regarding the repair of her fractured knee. The office visit consists of a detailed history, detailed examination, and medical decision making of moderate complexity. What CPT code is assigned? A. 99213 B. 99212 C. 99211 D. 99214 8. Intramuscular nonhormonal antineoplastic chemotherapy administration would be assigned to code A. 96402. B. 96405. C. 96406. D. 96401. 9. Home infusion with specialty drug administration during a 6-hour visit would be assigned what codes? A. 99606, 99607 ×3 B. 99601, 99602 ×4 C. 99604, 99605 ×2 D. 99603, 99604 ×2 10. A patient is seen for a psychiatric diagnostic evaluation. The physician obtains a complete history of the patient's mental status and does a complete biological and psychosocial assessment along with a complete physical examination. The physician's final diagnosis is recurrent episode of severe major depressive disorder, without any psychotic behavior involved. The patient also has a history of psychological trauma. What codes are assigned? A. F33.2, Z91.49 B. F33.1, Z91.47 C. F34.2, Z91.49 D. F36.2, Z91.46 11. A 17-year-old patient is diagnosed with a severe form of nutritional anemia. What ICD-10-CM code should be assigned? A. D45.9 B. D53.9 C. D74.9 D. D65.9 12. A 32-year-old patient receives anesthesia for spinal surgery. The anesthesia is complicated by utilization of controlled hypotension. What add-on anesthesia code would be assigned? A. 99174 B. 92117 C. 9910 ...
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CPT Medical Coding Assigment My Nursing Assignment.docx
This document contains a series of medical coding questions and answers related to CPT and ICD-10 coding. It includes questions testing knowledge of HIPAA privacy rules, medical terminology, anatomy, diagnostic and procedural coding, modifier usage, and other topics relevant to medical billing and coding. The questions are multiple choice and range from basic to more advanced concepts.
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This document contains a series of medical coding questions and answers related to CPT and ICD-10 coding. It includes 62 multiple choice questions covering topics such as HIPAA privacy rules, medical terminology, anatomy, procedures, modifiers, and reimbursement. The questions assess knowledge of medical coding principles, guidelines, and code sets.
Medical Coding ICD-101. This 60-year-old patient was admitted .docx
Medical Coding ICD-10
1. This 60-year-old patient was admitted with emphysematous nodules. A thoracoscopic wedge resection was performed in the left lung to remove the lung nodules. A resection was done in the upper and lower lobes. Which of the following answers is correct? (Points : 2)
J98.4, 32666, 32667
J43.9, 32666
J98.4, 32505
J43.9, 32666, 32667
Question 2. 2. A neonatal patient is brought to the operating room for repair of complete transposition of the great arteries under cardiopulmonary bypass. The infant is in critical condition and may not survive. Assign the correct diagnosis codes and CPT codes to report the administration of anesthesia, including physical status, Level I and II modifiers, and qualifying conditions for this procedure. (Points : 2)
Q20.3, 00562–AA–23, 99100
Q20.1, 00561–AD–P5, 99140
Q20.3, 00561–AA–P5
Q20.3, 00563–AA–P5, 99100, 99140
Question 3. 3. A 69-year-old patient was hit by a car, causing intra-thoracic trauma and hemorrhage. The patient was taken directly from the Emergency Department to the operative suite where the chest was opened and hemorrhage was controlled, but the patient’s heart stopped. Open heart massage was performed but the patient expired before the patient could be admitted. Assign the appropriate CPT code(s) and any required modifier(s) to report this service. (Points : 2)
32110-CA
32110, 32160
32160-CA
32110-CA, 32160-CA
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Z51.12, I49.8, 96401, J9213
C14.8, 96372, J9213
C06.9, C00.2, 96372
Z51.12, 96549
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T82.7XXA, L02.219, 33222
L02.219, 33222
T82.7XXA, 33223
T82.857A, L02.219, 33999
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J15.9
J69.0
J18.9
J69.1
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Q66.6, 29450
M21.549, 29405
Q66.0, 29405
...
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Need by 09.16.2015
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Patient had a left femoral hemiorraphy for a recurrent hernia, what is the correct code assignment?
C. 49555
A patient was taken to the endoscopy suite. The endoscopy was passed into the esophagus and continued into the duodenal bulb. Based on this documentation, what CPT code would be selected to represent this procedure?
43200
43234
43235
43260
Which of the following is not coded separately from the coronary artery bypass procedure?
Upper extremity artery
Upper extremity vein
Saphenous vein
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Which of the following CPT codes should be used for an emergency curettage due to retained placenta after normal vaginal delivery?
58120
59160
49320
59840
How do you code a retropubic subtotal prostatectomy?
B. 55831
Treatment of a missed abortion, completed surgically a 22 weeks is coded as?
C. 59821
Which of the following CPT codes describes the surgical removal of kidney stones through an incision in the body of the kidney.
D.50060
The patient undergoes the closure of a nephrocutaneous fistula, how is this coded?
B. 50520
The patient provides a kidney to a sibling who has renal failure. An open procedure is performed. How is this coded?
B. 50320
10. Principles of ICD-9-CM coding for ambulatory care encounters includes.
A. Ambulatory care diagnoses should be coded to the highest of certainly at the conclusion of the encounter.
B. Code suspected diagnoses as if the disease or injury existed.
C. conditions previously treated and no longer existing are coded.
D.Only the most significant diagnosis should be coded.
Level
2 codes of the HCPCS coding system are maintained by the:
D.Center for medicare and Medicaid services.
J1020 injection methylprednisolone acetate, 20 mg is an example of a
C. Level 2 code
Level one of HCPCS consists of
CPT codes
The inclusion of a code in COT indicates that the procedure is:
Commonly performed across the country
Endorsed by the AMA
Reimbursed by third party payers
The three key components used in defining the levels of E/M services are:
History, examination, medical decision making.
The differences between a new patient and an established patient is whether the patient received professional services from the physician or another physician of the same specialty who belongs to the same group of practice
Within the past three years
Mary Cole, who is recovering from pneumonia, returns to her physicians for follow up. Dr. Small reviews a recent x-ray, performs a problem focus examination followed by a short discussion of findings. CPT code assigned.
99212
Refer to the medical decision making table in your CPT book. Given the following information determine the type of medical decisi.
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1. This 60-year-old patient was admitted with emphysematous nodules. A thoracoscopic wedge resection was performed in the left lung to remove the lung nodules. A resection was done in the upper and lower lobes. Which of the following answers is correct? (Points : 2)
J98.4, 32666, 32667
J43.9, 32666
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Q20.3, 00562–AA–23, 99100
Q20.1, 00561–AD–P5, 99140
Q20.3, 00561–AA–P5
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32110-CA
32110, 32160
32160-CA
32110-CA, 32160-CA
Question 4. 4. A non-Medicare patient with carcinoma of the oral cavity and lower lip is receiving daily intramuscular injections of the interferon alfa-2a (3 million units) in the outpatient cancer center. Which of the following will be reported for this service? The payer does accept HCPCS Level II codes for drugs. (Points : 2)
Z51.12, I49.8, 96401, J9213
C14.8, 96372, J9213
C06.9, C00.2, 96372
Z51.12, 96549
Question 5. 5. An elderly patient has an abscess formation around a pacemaker pocket on his chest wall that requires that the device be removed and the pocket reformed in another location. Which of the following code sets is appropriate for this outpatient surgical service? (Points : 2)
T82.7XXA, L02.219, 33222
L02.219, 33222
T82.7XXA, 33223
T82.857A, L02.219, 33999
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J15.9
J69.0
J18.9
J69.1
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Q66.6, 29450
M21.549, 29405
Q66.0, 29405
...
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You CAN NOT google these questions for the answers.
Must be CPC, CCS, or RHIT certified coder.
Please check 40 that are answered, 40 that are unanswered.
Need by 09.16.2015
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Patient had a left femoral hemiorraphy for a recurrent hernia, what is the correct code assignment?
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A patient was taken to the endoscopy suite. The endoscopy was passed into the esophagus and continued into the duodenal bulb. Based on this documentation, what CPT code would be selected to represent this procedure?
43200
43234
43235
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Saphenous vein
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58120
59160
49320
59840
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B. 50520
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B. 50320
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A. Ambulatory care diagnoses should be coded to the highest of certainly at the conclusion of the encounter.
B. Code suspected diagnoses as if the disease or injury existed.
C. conditions previously treated and no longer existing are coded.
D.Only the most significant diagnosis should be coded.
Level
2 codes of the HCPCS coding system are maintained by the:
D.Center for medicare and Medicaid services.
J1020 injection methylprednisolone acetate, 20 mg is an example of a
C. Level 2 code
Level one of HCPCS consists of
CPT codes
The inclusion of a code in COT indicates that the procedure is:
Commonly performed across the country
Endorsed by the AMA
Reimbursed by third party payers
The three key components used in defining the levels of E/M services are:
History, examination, medical decision making.
The differences between a new patient and an established patient is whether the patient received professional services from the physician or another physician of the same specialty who belongs to the same group of practice
Within the past three years
Mary Cole, who is recovering from pneumonia, returns to her physicians for follow up. Dr. Small reviews a recent x-ray, performs a problem focus examination followed by a short discussion of findings. CPT code assigned.
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CHAPTER 15 r Evaiuation and Management (EM) Services,fA,.docx
CHAPTER 15 r Evaiuation and Management (E/M) Services
,/fA, four types of medical decision making, in order of complexity from most to
List the fi
least risk
,d--A-
A-
,lr,
-lr-
Inpatient time spent at the bedside or nursing station during or after
the visit is what kind of time?
21. Thepatient's will reflect the
. nrm-ber of systems examined by a brief statement of the findings.
/ZZ. I discussion with a patient andlor family concerning one or more of
the following areas: diagnostic results, impressions and/or
recommended diagnostic studies; prognosis; risks and benefits of
treatment; instruciions for treatment; importance of compliance with
treatment; risk factor reduction; and patient and family education is
23. The history is the
physician.
information the Patient tells the
Ol4r11bcrd .rasvl-crs are located in Appendix B, while the full answer key ls only available in the TEACE
Iffir Ecsorrrces on Erolve.
-4
,r{
/n.
,{
13. Complexity of medical decision making is based on three
ve types of presenting problems from the most risk and least recovery to
and most recovery:
19. Counseling and coordination of care are what kind of factors in most
cases?
U/O. ,r*"that is used as a guide for outpatient services is what kind of time?
Cop].right @ 2015 by Saunders, an impdnt of Elsevier Inc' A1I rights reserved'
CHAI{ER 15 r Evaluation and Management (E/l[l Sersices
6n. ,n"re is no distinction made between the new and established patients
in this service department of a hospital:
25. Those services rendered by a physician whose opinion or advice is
requested by another physician or agency in the evaluation and/or
treatment of a patient is a(n) whereas the
physician who has primary responsibility for the patient in the hospital
is called
r'26. Whencritically ill patients in medical emergencies require the constant
attendance of the physician (e.g., cardiac arrest, shock, bleeding, and
respiratory failure) to stabilize them, what kind of care is needed?
27. When care is provided
same patient by more
conditions, the care is
for similar services
than one physician
(e.g., hospital visits) to the
on the same day for different
,6. *nuris the name for the assumption of the total or speciflc care of a
patient from one physician to another that does not constitute a
consultation?
29. An inventory of body systems obtained
signs and/or symptoms that the patient
."{o. ,tthe physician who is standing by does so for 25 minutes, can he ot
she round the time up to 30 minutes for reporting purposes?
through questioning to identifY
may be experiencing is a(n)
of
Odd-numbered answers are located in Appendlx B, while the full answer key is only avaitrablc ir ft TEI'€E
Instructor Resources on Evolve.
Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.
CIL{PTER 15 r fyil*5on irnd Management (E/}vf) Services
PRACTICAT
Office or Other Outpatlent Services and Hospltal lnpatient Service
With the use of t.
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A 55-year-old woman was admitted to the intensive care unit (ICU) with vomiting, seizures, and probable aspiration. She has a history of hypertension, COPD, and a prior heart attack. Family reports she smokes daily and drinks alcohol continuously. In the emergency room, she presented with recurrent vomiting, seizures, respiratory distress, and anxiety. Labwork showed elevated liver enzymes and normal blood work. She was intubated and transferred to the ICU.
10Running Head Modulo 2 Plan de Cuidado- (cuidado holíst
10
Running Head: Modulo 2 Plan de Cuidado- (cuidado holístico)
Situación Hipotética
A 55-year-old woman admitted 2 days ago to the Intensive Care Unit. The admission diagnoses are: vomiting, seizures, and probable aspiration. She has a prior history of hypertension, COPD, and myocardial infarction with angioplasty performed six months ago.
Family members report that the client uses the following routine medications: Toprol 50mg 1 tab. daily, Lipitor 20 mg 1 tab. daily, Aspirin 81 mg 1ab. Daily, Plavix 75 mg 1 tab. daily; He smokes a daily pack of cigarettes since he was 30 years old. They also report that the patient drinks alcohol continuously; "In the last 3 days I have found her drunk in the house" said the woman's nephew.
The patient is 5'11'' and weighs approximately 180 pounds. Upon arrival at the emergency room she presents vital signs of: T-37°C, P-150/min., R-28/min. and B/P-193/124 mmHg. She is observed with recurrent vomiting and severe episodes of seizures, respiratory distress, and severe anxiety. Dr. Díaz orders ABG's which result in: pH-7.30, PaCO 2 -50 mmHg, PO 2 -81 mmHg and NaHCO 3 -23 mEq/L, Sat. 85%. The client is sedated with Propofol 5mL, for oroendotracheal intubation and transferred to the ICU area. Blood pressure after intubation medication decreased to 80/52 mmHg. She is restricted to patient per intubation protocol. Laboratory samples show elevated liver enzymes, elevated cholesterol and triglycerides, and normal CBC.
Introduction:
Aspiration pneumonia is caused by aspiration of oropharyngeal contents into the airways, leading to abscess lesions due to bacterial infection in the lower lung lobes. It generally occurs in patients with frequent seizures and loss of mental status, with impaired swallowing of food or loss of the gag reflex (Aspiration pneumonia, n.d.). In this work we will carry out the care plan and the nursing progress notes of a 55-year-old female patient admitted to the Intensive Care Unit with respiratory distress probably caused by pneumonia due to aspiration of her own vomit, leading her to a state of acute respiratory acidosis with adequate bicarbonate compensation by the kidney.
Care Plan:
Estimado
Diagnóstico de Enfermería
Expected results
Nursing Interventions
Evaluatión
domains
Needs
maladaptive behaviors
Focal Stimulus
Interventions
Scientific Rational
subjective data
Objective data
Domain 3: Elimination
Need 1: Breathe normally
The patient reports shortness of breath and that he is anxious
The patient is observed with labored breathing with RF at 28/min with abnormal arterial pH.
respiratory distress
(00030 Impaired gas exchange r/c ventilation-perfusion imbalance m/p shortness of breath, hypoxemia, and abnormal arterial pH.
The patient will recover her adequate ventilation after treatment, in a period of approximately 48 hours.
Domain 1: Security/ protection.
Need 1: Have no aspiration risks
Family me ...
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The revised discharge policy is aligned with the COVID-19 clinical management protocol, guidelines for
home isolation of mild COVID-19 cases and advisory on Covid-19 testing strategy issued by Ministry of
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Airway: Patency Position of artificial airway (if present)
Breathing: Quantity and quality of respirations (rate, depth, pattern, symmetry, effort, use of accessory muscles) Breath sounds Presence of spontaneous breathing.
Circulation and Cerebral Perfusion: ECG (rate, rhythm, and presence of ectopy) Blood pressure Peripheral pulses and capillary refill Skin, color, temperature, moisture Presence of bleeding Level of consciousness, responsiveness.
quick Check Assessment in CCU.
Head Trauma Final
1. A 41-year-old female presented to the emergency department after falling from a wheelie bin and hitting her head one day prior. She had been experiencing worsening headache and was found to have bleeding from her left ear with an altered mental status.
2. A CT scan revealed an acute right-sided subdural hematoma with midline shift. She subsequently underwent a right fronto-parietal craniotomy.
3. A follow-up CT showed evidence of the recent craniotomy with swelling, as well as a small focus of evolving hematoma in the right temporal lobe and some residual midline shift.
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Diagnostic Coding: ICD-10-CM
Assignment 1.3
Diagnostic Coding: ICD-10-CM
W6: Coding
Your Name:
Part 1
Instructions: Review each case and identify the first-listed diagnosis.
1. Pain, left knee. History of injury to left knee 20 years ago. Patient underwent arthroscopic surgery and medial meniscectomy, right knee (10 years ago). Probable arthritis, left knee.
FIRST-LISTED DIAGNOSIS: ________
2. Patient admitted to the emergency department (ED) with complaints of severe chest pain. Possible myocardial infarction. EKG and cardiac enzymes revealed normal findings. Diagnosis upon discharge was gastroesophageal reflux disease.
FIRST-LISTED DIAGNOSIS: ______
3. Female patient seen in the office for follow-up of hypertension. The nurse noticed upper arm bruising on the patient and asked how she sustained the bruising. The physician renewed the patient’s hypertension prescription, hydrochlorothiazide.
FIRST-LISTED DIAGNOSIS: _______
4. Ten-year-old male seen in the office for sore throat. Nurse swabbed patient’s throat and sent swabs to the hospital lab for strep test. Physician documented “likely strep throat” on the patient’s record.
FIRST-LISTED DIAGNOSIS: _____
5. Patient was seen in the outpatient department to have a lump in his abdomen evaluated and removed. Surgeon removed the lump and pathology report revealed that the lump was a lipoma.
FIRST-LISTED DIAGNOSIS: _____
Part 2
Instructions: Match the diagnosis in the right-hand column with the procedure/service in the left-hand column that justifies medical necessity.
E 6. allergy test a. bronchial asthma
B 7. EKG b. chest pain
A 8. inhalation treatment c. family history, cervical cancer
C 9. Pap smear d. fractured wrist
G 10. removal of ear wax e. hay fever
I_ 11. sigmoidoscopy f. hematuria
J 12. strep test g. impacted cerumen
F 13. urinalysis h. jaundice
H 14. venipuncture i. rectal bleeding
D 15. X-ray, radius and ulna j. sore throat
Part 3
Instructions: Review the following SOAP notes or Operative reports to select the diagnoses that should be reported on the CMS-1500 claim. Then assign ICD-10-CM codes to diagnoses. (The level of service is indicated for each visit.)
16.
S: A 53-year-old new patient was seen today for a level 2 visit. The female patient presents with complaints of polyuria, polydipsia, and weight loss.
O: Urinalysis by dip, automated, with microscopy reveals elevated glucose.
A: Possible diabetes.
P: The patient is to have a glucose tolerance test and return in three days for her blood work results and applicable management of care.
Diagnoses
ICD Codes
Polyuria
R35.8
polydipsia
R63.1
weight loss
R63.4
Urinalysis
R81
17.
PREOPERATIVE DIAGNOSIS: Ventral hernia
POSTOPERATIVE DIAGNOSIS: Ventral hernia
PROCEDURE PERFORMED: Repair of ventral hernia with mesh
ANESTHESIA: General
PROCEDURE: The vertical midline incision was opened. Sharp and blunt dissection was used in defining the hernia .
Kazaam Company, a merchandiser, recently completed its calendar-year.docx
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Katharine Hepburn, Harvey Milk, and Fred Karomatsu all contrib.docx
Katharine Hepburn, Harvey Milk,
and
Fred Karomatsu
all contributed to social change in America in the areas of gender or “race”.
Explain who each person was, what issues they were dealing with, and what method or methods they used to try to create social change. Be clear on what role the media of the times played (or did not play) in their actions. Was there a method (or methods) that you feel were more effective than others? Why?
Essays should be about two to three pages double-spaced, about 600-800 words.
.
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An indented CPT code includes the portion of the stand-alone code description preceding the semicolon, which specifies the extent of the service, specific anatomic site, and additional tests. Physical status modifiers are appended to codes in the Surgery section. When a panel test is performed with additional pathology/laboratory tests, the additional tests should be reported separately in addition to the panel code. A bronchoscopy can be either a surgical or diagnostic procedure and is sometimes performed unilaterally or bilaterally.
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This document contains 20 multiple choice questions related to coding for integumentary, cardiovascular, and sensory systems. The questions cover topics like coding breast and skin procedures, hearing aids, hip arthroscopy, congestive heart failure, skin grafts, breast and eye procedures, hypertension, diabetes, kidney disease, lacerations, and biopsies of the cornea and lacrimal gland. Correct coding of ICD-10 diagnoses and CPT/HCPCS procedure codes is tested based on patient case scenarios.
CHAPTER 15 r Evaiuation and Management (EM) Services,fA,.docx
CHAPTER 15 r Evaiuation and Management (E/M) Services
,/fA, four types of medical decision making, in order of complexity from most to
List the fi
least risk
,d--A-
A-
,lr,
-lr-
Inpatient time spent at the bedside or nursing station during or after
the visit is what kind of time?
21. Thepatient's will reflect the
. nrm-ber of systems examined by a brief statement of the findings.
/ZZ. I discussion with a patient andlor family concerning one or more of
the following areas: diagnostic results, impressions and/or
recommended diagnostic studies; prognosis; risks and benefits of
treatment; instruciions for treatment; importance of compliance with
treatment; risk factor reduction; and patient and family education is
23. The history is the
physician.
information the Patient tells the
Ol4r11bcrd .rasvl-crs are located in Appendix B, while the full answer key ls only available in the TEACE
Iffir Ecsorrrces on Erolve.
-4
,r{
/n.
,{
13. Complexity of medical decision making is based on three
ve types of presenting problems from the most risk and least recovery to
and most recovery:
19. Counseling and coordination of care are what kind of factors in most
cases?
U/O. ,r*"that is used as a guide for outpatient services is what kind of time?
Cop].right @ 2015 by Saunders, an impdnt of Elsevier Inc' A1I rights reserved'
CHAI{ER 15 r Evaluation and Management (E/l[l Sersices
6n. ,n"re is no distinction made between the new and established patients
in this service department of a hospital:
25. Those services rendered by a physician whose opinion or advice is
requested by another physician or agency in the evaluation and/or
treatment of a patient is a(n) whereas the
physician who has primary responsibility for the patient in the hospital
is called
r'26. Whencritically ill patients in medical emergencies require the constant
attendance of the physician (e.g., cardiac arrest, shock, bleeding, and
respiratory failure) to stabilize them, what kind of care is needed?
27. When care is provided
same patient by more
conditions, the care is
for similar services
than one physician
(e.g., hospital visits) to the
on the same day for different
,6. *nuris the name for the assumption of the total or speciflc care of a
patient from one physician to another that does not constitute a
consultation?
29. An inventory of body systems obtained
signs and/or symptoms that the patient
."{o. ,tthe physician who is standing by does so for 25 minutes, can he ot
she round the time up to 30 minutes for reporting purposes?
through questioning to identifY
may be experiencing is a(n)
of
Odd-numbered answers are located in Appendlx B, while the full answer key is only avaitrablc ir ft TEI'€E
Instructor Resources on Evolve.
Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.
CIL{PTER 15 r fyil*5on irnd Management (E/}vf) Services
PRACTICAT
Office or Other Outpatlent Services and Hospltal lnpatient Service
With the use of t.
Emergency nursing questionnaires
This document contains 10 multiple choice questions related to nursing care in emergency situations. The questions cover topics like priority interventions for a client with chest pain, appropriate treatment for anaphylaxis, identifying fracture types, appropriate work for a float nurse, purpose of glucagon, correct placement of defibrillator pads, assessing bowel sounds, priority care for a chemical eye splash, concerning findings after hip replacement, and appropriate seizure precautions.
Drill 4
The document contains a competency appraisal exam with multiple choice questions covering various situations in perioperative nursing. It addresses topics like the roles and responsibilities of the surgical team members, preoperative and postoperative care of surgical patients, management of specific conditions like asthma and colostomy, safety protocols in the operating room, and maintenance of medical records. The exam evaluates the examinee's knowledge on providing efficient and quality patient care in the perioperative setting.
Module 2 KEY POLICIES.pptx
1. The document outlines various admission, discharge, and patient transfer policies and procedures for a regional orthopaedic center.
2. Key policies include proper patient endorsement, validation of patient information and medical documentation, and arrangement of forms in the patient's file.
3. Procedures specify the responsibilities of nurses in receiving and preparing patients, validating orders, updating patient records and files, and communicating necessary information during transfers between units.
Feb 2016 iep
The document outlines trauma admission guidelines and response times for specialists at Monroe Carell Jr. Children's Hospital. It provides guidelines for admitting trauma patients based on their injuries and conditions. It also establishes response time requirements for specialists, including the trauma service responding within 15 minutes for level I activations, neurosurgery and spine responding within 30 minutes for indications like increased ICP or unstable spine, and orthopedics responding within 30 minutes for acute limb issues or within 1 hour for open fractures.
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This document describes a scenario where a patient suffered a sentinel event during treatment at a rural hospital emergency department. The patient, Mr. B, arrived at the ED after falling and was found to have a fractured hip. After being sedated for reduction of the hip, his condition deteriorated and he became unresponsive. Resuscitation efforts were unsuccessful and he was transferred to another hospital where he was later declared brain dead and life support was removed. The task is to conduct a root cause analysis of the sentinel event, develop an improvement plan using change theory, and conduct a failure mode and effects analysis to reduce the likelihood of recurrence. Key roles for nurses in improving quality of care are also discussed.
10Running Head Modulo 2 Plan de Cuidado- (cuidado holíst
A 55-year-old woman was admitted to the intensive care unit (ICU) with vomiting, seizures, and probable aspiration. She has a history of hypertension, COPD, and a prior heart attack. Family reports she smokes daily and drinks alcohol continuously. In the emergency room, she presented with recurrent vomiting, seizures, respiratory distress, and anxiety. Labwork showed elevated liver enzymes and normal blood work. She was intubated and transferred to the ICU.
10Running Head Modulo 2 Plan de Cuidado- (cuidado holíst
10
Running Head: Modulo 2 Plan de Cuidado- (cuidado holístico)
Situación Hipotética
A 55-year-old woman admitted 2 days ago to the Intensive Care Unit. The admission diagnoses are: vomiting, seizures, and probable aspiration. She has a prior history of hypertension, COPD, and myocardial infarction with angioplasty performed six months ago.
Family members report that the client uses the following routine medications: Toprol 50mg 1 tab. daily, Lipitor 20 mg 1 tab. daily, Aspirin 81 mg 1ab. Daily, Plavix 75 mg 1 tab. daily; He smokes a daily pack of cigarettes since he was 30 years old. They also report that the patient drinks alcohol continuously; "In the last 3 days I have found her drunk in the house" said the woman's nephew.
The patient is 5'11'' and weighs approximately 180 pounds. Upon arrival at the emergency room she presents vital signs of: T-37°C, P-150/min., R-28/min. and B/P-193/124 mmHg. She is observed with recurrent vomiting and severe episodes of seizures, respiratory distress, and severe anxiety. Dr. Díaz orders ABG's which result in: pH-7.30, PaCO 2 -50 mmHg, PO 2 -81 mmHg and NaHCO 3 -23 mEq/L, Sat. 85%. The client is sedated with Propofol 5mL, for oroendotracheal intubation and transferred to the ICU area. Blood pressure after intubation medication decreased to 80/52 mmHg. She is restricted to patient per intubation protocol. Laboratory samples show elevated liver enzymes, elevated cholesterol and triglycerides, and normal CBC.
Introduction:
Aspiration pneumonia is caused by aspiration of oropharyngeal contents into the airways, leading to abscess lesions due to bacterial infection in the lower lung lobes. It generally occurs in patients with frequent seizures and loss of mental status, with impaired swallowing of food or loss of the gag reflex (Aspiration pneumonia, n.d.). In this work we will carry out the care plan and the nursing progress notes of a 55-year-old female patient admitted to the Intensive Care Unit with respiratory distress probably caused by pneumonia due to aspiration of her own vomit, leading her to a state of acute respiratory acidosis with adequate bicarbonate compensation by the kidney.
Care Plan:
Estimado
Diagnóstico de Enfermería
Expected results
Nursing Interventions
Evaluatión
domains
Needs
maladaptive behaviors
Focal Stimulus
Interventions
Scientific Rational
subjective data
Objective data
Domain 3: Elimination
Need 1: Breathe normally
The patient reports shortness of breath and that he is anxious
The patient is observed with labored breathing with RF at 28/min with abnormal arterial pH.
respiratory distress
(00030 Impaired gas exchange r/c ventilation-perfusion imbalance m/p shortness of breath, hypoxemia, and abnormal arterial pH.
The patient will recover her adequate ventilation after treatment, in a period of approximately 48 hours.
Domain 1: Security/ protection.
Need 1: Have no aspiration risks
Family me ...
ICU Protocols
1. The trauma protocol outlines the assessment and management of critically injured patients according to ATLS guidelines, with a focus on the ABCs - airway, breathing, circulation, disability and exposure.
2. Interventions include securing the airway with bag-valve-mask ventilation or intubation, assessing breathing with pulse oximetry and chest x-rays, supporting circulation with IV access and fluid boluses, evaluating neurologic status via GCS, and conducting a full secondary survey and spinal precautions.
3. Additional tests such as FAST scan, pelvic films and head/neck CTs help guide management, which may involve mechanical ventilation, chest tube insertion, blood transfusion, pelvic binding, wound
Revised dischargepolicyforcovid19updatedon9thjanuary2022
The revised discharge policy is aligned with the COVID-19 clinical management protocol, guidelines for
home isolation of mild COVID-19 cases and advisory on Covid-19 testing strategy issued by Ministry of
Health & FW.
Csq arb2012-sec3
This document summarizes guidelines for oxygen therapy in post-operative care. It recommends that oxygen therapy is an important part of recovery and can reduce post-operative complications. The summary outlines standards for best practice, such as all patients in recovery receiving oxygen according to local guidelines, and all high-risk patients who could benefit from post-operative oxygen being prescribed it and using it correctly. Audit indicators are proposed to measure adherence to these standards.
Pre operative and post-operative surgical care - a brief medical study
1. The document discusses pre-operative and post-operative surgical care including pre-operative evaluation and preparation, specific risk factors affecting operative risk, pre-operative orders, post-operative management, and common post-operative complications.
2. The pre-operative evaluation involves a comprehensive health assessment including history, exam, investigations, and informed consent to assess patient health and surgical risks.
3. Post-operative care focuses on monitoring vitals, intravenous fluids, analgesics, diet advancement, antibiotics if needed, and managing complications like hemorrhage, infection, and pyrexia.
Drill 8
This document contains 49 multiple choice questions related to caring for clients with various neurological conditions and injuries. The questions cover topics like increased intracranial pressure, meningitis, stroke, seizures, cranial nerve impairments, and burns. Response options involve assessing clients, interpreting test results, identifying appropriate nursing interventions, recognizing risk factors, and selecting priority concerns.
A C S0105 Postoperative Management Of The Hospitalized Patient
This document discusses postoperative management of surgical patients. It describes the different levels of postoperative care including same-day surgery, the surgical floor, telemetry ward, and intensive care unit. Factors determining a patient's disposition include their preoperative health, procedure performed, and postoperative clinical status. The document also discusses common postoperative orders related to tubes, drains, oxygen therapy, and wound care to guide nursing staff.
Nursing management of critically ill patient in intensive care units
Critical care nursing: it is the field of nursing with a focus on the utmost care of the critically ill (or) unstable patients.
Critically ill patients : critically ill patients are those who are at risk for actual (or) potential life threatening health problems.
Admission QGeneral appearance (consciousness)
Airway: Patency Position of artificial airway (if present)
Breathing: Quantity and quality of respirations (rate, depth, pattern, symmetry, effort, use of accessory muscles) Breath sounds Presence of spontaneous breathing.
Circulation and Cerebral Perfusion: ECG (rate, rhythm, and presence of ectopy) Blood pressure Peripheral pulses and capillary refill Skin, color, temperature, moisture Presence of bleeding Level of consciousness, responsiveness.
quick Check Assessment in CCU.
Head Trauma Final
1. A 41-year-old female presented to the emergency department after falling from a wheelie bin and hitting her head one day prior. She had been experiencing worsening headache and was found to have bleeding from her left ear with an altered mental status.
2. A CT scan revealed an acute right-sided subdural hematoma with midline shift. She subsequently underwent a right fronto-parietal craniotomy.
3. A follow-up CT showed evidence of the recent craniotomy with swelling, as well as a small focus of evolving hematoma in the right temporal lobe and some residual midline shift.
immune dysregulation following COVID - case study.pptx
clinical cases and a brief discussion of COVID infection and\or vaccination on the eye health , the cases were diagnosed within a short period after the patients aquired either a corona general infection or corona vaccination .
Diagnostic Coding ICD-10-CMAssignment 1.3Diagnostic C.docx
Diagnostic Coding: ICD-10-CM
Assignment 1.3
Diagnostic Coding: ICD-10-CM
W6: Coding
Your Name:
Part 1
Instructions: Review each case and identify the first-listed diagnosis.
1. Pain, left knee. History of injury to left knee 20 years ago. Patient underwent arthroscopic surgery and medial meniscectomy, right knee (10 years ago). Probable arthritis, left knee.
FIRST-LISTED DIAGNOSIS: ________
2. Patient admitted to the emergency department (ED) with complaints of severe chest pain. Possible myocardial infarction. EKG and cardiac enzymes revealed normal findings. Diagnosis upon discharge was gastroesophageal reflux disease.
FIRST-LISTED DIAGNOSIS: ______
3. Female patient seen in the office for follow-up of hypertension. The nurse noticed upper arm bruising on the patient and asked how she sustained the bruising. The physician renewed the patient’s hypertension prescription, hydrochlorothiazide.
FIRST-LISTED DIAGNOSIS: _______
4. Ten-year-old male seen in the office for sore throat. Nurse swabbed patient’s throat and sent swabs to the hospital lab for strep test. Physician documented “likely strep throat” on the patient’s record.
FIRST-LISTED DIAGNOSIS: _____
5. Patient was seen in the outpatient department to have a lump in his abdomen evaluated and removed. Surgeon removed the lump and pathology report revealed that the lump was a lipoma.
FIRST-LISTED DIAGNOSIS: _____
Part 2
Instructions: Match the diagnosis in the right-hand column with the procedure/service in the left-hand column that justifies medical necessity.
E 6. allergy test a. bronchial asthma
B 7. EKG b. chest pain
A 8. inhalation treatment c. family history, cervical cancer
C 9. Pap smear d. fractured wrist
G 10. removal of ear wax e. hay fever
I_ 11. sigmoidoscopy f. hematuria
J 12. strep test g. impacted cerumen
F 13. urinalysis h. jaundice
H 14. venipuncture i. rectal bleeding
D 15. X-ray, radius and ulna j. sore throat
Part 3
Instructions: Review the following SOAP notes or Operative reports to select the diagnoses that should be reported on the CMS-1500 claim. Then assign ICD-10-CM codes to diagnoses. (The level of service is indicated for each visit.)
16.
S: A 53-year-old new patient was seen today for a level 2 visit. The female patient presents with complaints of polyuria, polydipsia, and weight loss.
O: Urinalysis by dip, automated, with microscopy reveals elevated glucose.
A: Possible diabetes.
P: The patient is to have a glucose tolerance test and return in three days for her blood work results and applicable management of care.
Diagnoses
ICD Codes
Polyuria
R35.8
polydipsia
R63.1
weight loss
R63.4
Urinalysis
R81
17.
PREOPERATIVE DIAGNOSIS: Ventral hernia
POSTOPERATIVE DIAGNOSIS: Ventral hernia
PROCEDURE PERFORMED: Repair of ventral hernia with mesh
ANESTHESIA: General
PROCEDURE: The vertical midline incision was opened. Sharp and blunt dissection was used in defining the hernia .
Similar to 1. Anesthesia administered to a normal, healthy patient underg (20)
CHAPTER 15 r Evaiuation and Management (EM) Services,fA,.docx
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Organizational Systems and Leadership Root Cause Analysis.docx
Organizational Systems and Leadership Root Cause Analysis.docx
10Running Head Modulo 2 Plan de Cuidado- (cuidado holíst
10Running Head Modulo 2 Plan de Cuidado- (cuidado holíst
10Running Head Modulo 2 Plan de Cuidado- (cuidado holíst
10Running Head Modulo 2 Plan de Cuidado- (cuidado holíst
Revised dischargepolicyforcovid19updatedon9thjanuary2022
Revised dischargepolicyforcovid19updatedon9thjanuary2022
Pre operative and post-operative surgical care - a brief medical study
Pre operative and post-operative surgical care - a brief medical study
A C S0105 Postoperative Management Of The Hospitalized Patient
A C S0105 Postoperative Management Of The Hospitalized Patient
Nursing management of critically ill patient in intensive care units
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immune dysregulation following COVID - case study.pptx
immune dysregulation following COVID - case study.pptx
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), the second most expensive in the world after Narita's. In the early years of the airport's operation, excessive terminal rent and
UTILITY BILLS
for on-site concessions also drove up operating costs: some estimates before opening held that a cup of coffee would have to cost US$10.
[19]
Osaka business owners pressed the government to take a greater burden of the construction cost to keep the airport attractive to passengers and airlines.
[20]
On 17 February 2005,
Chubu Centrair International Airport
opened in
Nagoya
, just east of Osaka. The opening of the airport was expected to increase competition between Japan's international airports. Despite this, passenger totals were up 11% in 2005 over 2004, and international passengers increased to 3.06 million in 2006, up 10% over 2005. Adding to the competition was the opening of Kobe Airport, less than 25 km (16 mi) away, in 2006 and the lengthening of the runway at
Tokushima Airport
in
Shikoku
in 2007. The main rationale behind the expansions was to compete with
Incheon International Airport
and
Hong Kong International Airport
as a gateway to Asia, as Tokyo area airports were severely congested. Kansai saw an 5% year-on-year increase in international traffic in summer 2013, largely supported by
low-cost carrier
traffic to
Taiwan
and Southeast Asia overcoming a decrease in traffic to China and
South Korea
.
[21]
The airport authority was allotted 4 billion yen in government support for fiscal year 2013, and the Ministry of Land, Infrastructure and Transport and Ministry of Finance have agreed to reduce this amount in stages through fiscal year 2015, although local governments in the Kansai region have pressed for
CONTINUED
subsidies.
[22]
Kansai has been marketed as an alternative to Narita Airport for international travelers from the
Greater Tokyo Area
. By flying to Kansai from
Haneda Airport
and connecting to
INTERNATIONAL FLIGHTS
there, travelers can save the additional time required to get to Narita: up to one and a half hours for many residents of
Kanagawa Prefecture
and southern Tokyo.
.
Juvenile JusticeInstructional Objectives for this activityExplo.docx
Juvenile Justice
Instructional Objectives for this activity:
Explore results of environment and SES issues.
This week you read about Social Reaction Theory, AKA Labeling Theory and Social Conflict Theory. For this week's class discussion, please consider this theory as you complete the discussion below.
Pick one popular television program or historical criminal event involving youth violence.
Review, research or observe the show or criminal media reports to determine if criminals or youth are portrayed as having negative physical characteristics, and police officers are portrayed as having positive physical characteristics.
Each student is to report her/his findings as a clearly labeled main post.
.
Juvenile Facing Life in Prison, we’re doing pros and cons.I a.docx
Juvenile Facing Life in Prison, we’re doing pros and cons.
I agree with Life in Prison without parole, and I have to cover the following:
When: Comparing crime, what states has juveniles committing more crimes, and rates through the years.
Why: Causes of the crimes (Felonies that deserve a sentence of life)
How: How it affects juveniles in the community.
If it;s done before 3/29/2015 better
.
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JUVENILE JUSTICE 2 ONLY ONE PARAGRAPH
Identify the critical need for confidentiality.
According to Siegel and Welsh (2012), the presence of gangs as a threatening force began in the 1950s and 1960s. Since then gang activity has become increasingly organized and connected to larger networks. For this week's class discussion, please complete the following:
Discuss the various forms of gang control used by law enforcement and community leaders today.
Share your suggestions on how these can be improved.
.
Journal Entry 3 Prepare a one to two (1-2) paragraph journal en.docx
Journal Entry 3:
Prepare a one to two (1-2) paragraph journal entry in which you make your recommendation to Jeff Passmore concerning the hospital’s liability in Mr. Davis’s case, as discussed within Learnscape 4: Failure to Obtain Consent. Include details from your conversation within the scenario to support your position. Give your opinion on whether or not the consent given by Mr. Davis was sufficient, prior to surgery.
.
Journal Positive Social Change—An Evolving PerspectiveAs explor.docx
Journal: Positive Social Change—An Evolving Perspective
As explored in the first week of this course, there is not one single definition for terms like social responsibility and social change. They are complex concepts determined by multiple factors. You may now recognize some of the key contributing factors that lead to social responsibility in action. Has your initial understanding of social responsibility and social change evolved through your work in this course?
In this last Journal Assignment, you reflect on how this course influences your overall understanding and approach to positive social change.
To prepare for this Assignment:
Review Walden University’s General Education Learning Outcome: “Change” in the Syllabus
.
Consider how the General Education DEEP-C model contributed to your ability to discover and evaluate ideas from different perspectives, and is instrumental in your progress toward achieving personal goals and effecting positive social change.
Revisit definitions of
social responsibility
shared in the Week 1 Discussion in light of all the information you have considered throughout this course.
Read Chapters 11 and 12 in the Loeb (2010) course text.
Reflect on the exercise in collective action represented by the Group Project. Think about the benefits collective action offers for accomplishing the goals of the Group Project.
The Assignment:
Writea 3- to 4-paragraph journal entry in which you briefly analyze the value of collective action in working toward social change.
Describe how your perspective has evolved or changed through this course and how you believe it will continue to evolve after the course.
How has this experience influenced your ability to create positive social change beyond the term of this course?
.
Journal Evaluating ResourcesPersonal experience and perception le.docx
Journal: Evaluating Resources
Personal experience and perception lend a great deal to addressing a social issue. However, as individuals, there are limits to one’s knowledge on any topic. The ability to conduct research on a social issue allows for a more comprehensive perspective on multiple aspects of an issue, insight into the communities impacted, and lessons learned for other like-minded groups who have done similar work.
In this Journal Assignment, you explore the concept
Discovery
as it relates your group's research on a social topic.
To prepare for this Assignment:
Consider the assigned readings from the first 3 weeks of this course.
Review the explanation of DEEP-C Model General Education Learning Outcome “Discovery” in the Syllabus.
Consider
“
Discovery” as it relates to the work you are doing in this course.
Bearing in mind the amount of information that is readily available in current times, think about how people involved in social movements of the past gained information on the social issue and related topics.
The Assignment:
Write
a 2- to 3-paragraph journal entry in which you address the following questions:
What appropriate sources of information will be used to support your group's claims about your topic?
At this early stage in the process of investigating your topic, what advantages do you see in conducting research to discover various factors associated with the topic?
In what ways does the ability to conduct research strengthen your group's approach?
General Education Learning Outcomes (The DEEP-C Model)
Discovery
:
Students will locate and identify appropriate sources of information using multiple sources and methods, including bibliographic, textual, experiential, and experimental research.
Evaluation:
Students will critically assess texts and arguments in multiple forms and contexts using quantitative and qualitative logic, the scientific method, ethics, and pragmatics.
Expression:
Students will effectively and ethically communicate information and opinions verbally and nonverbally using written, oral, behavioral, and visual methods adapted for diverse audiences and purposes.
Perspective
: Students will be able to articulate the consistency and flexibility of knowledge as it is experienced across time, space, and culture.
Change
: Students will articulate how their ability to discover, evaluate, and express ideas from different perspectives is instrumental in their progress toward achieving personal goals and effecting positive social change.
.
Journal Entry 3 Prepare a one to two (1-2) paragraph journal entr.docx
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1. Anesthesia administered to a normal, healthy patient underg
- 1. 1. Anesthesia administered to a normal, healthy patient undergoing an esophageal procedure is coded as A. 00500-P1. B. 00502-P1. C. 00500-P2. D. 00506-P1. 2. A new patient comes into the doctor's office for her annual gynecological exam. During the course of the exam, she undergoes a screening cervical cytopathology smear, which is performed by an automated system under the supervision of a physician. What HCPCS code is assigned? A. G0185 B. G7869 C. G7452 D. G0147
- 2. 3. A new patient is seen for a home visit that involves a comprehensive history, examination, and medical decision making of high complexity. What code should be assigned? A. 99349 B. 99345 C. 99342 D. 99350 4. A prolonged evaluation and management service before and/or after direct patient care for one hour is coded as A. 99359. B. 99358. C. 99361. D. 99360.
- 3. 5. A 57-year-old patient is admitted to the hospital for a hip arthroscopy procedure. The patient is a normal healthy patient with no systemic disease. What anesthesia CPT code should be assigned? A. 01242-P2 B. 01202-P1 C. 01202-P3 D. 01202-P5 6. Anesthesia for procedures performed on the larynx and trachea in an 11-month-old child would be assigned to code A. 00620. B. 00625. C. 00326. D. 00532.
- 4. 7. A patient returns for a follow-up office visit regarding the repair of her fractured knee. The office visit consists of a detailed history, detailed examination, and medical decision making of moderate complexity. What CPT code is assigned? A. 99213 B. 99212 C. 99211 D. 99214 8. Intramuscular nonhormonal antineoplastic chemotherapy administration would be assigned to code A. 96402. B. 96405. C. 96406. D. 96401.
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- 10. an osteotomy. D. anesthesia provided for a vulvectomy. 19. A 25-year-old patient receives a Hepatitis A vaccination. The vaccine is administered intramuscularly in the clinic. What CPT codes should be assigned? A. 90632, 90471 B. 90541, 90489 C. 90637, 90472 D. 90672, 90451 20. A dark adaptation examination with interpretation and report is assigned to code A. 92326. B. 92284. C. 92287.
- 11. D. 92325.