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Now that we have discussed all three of the code sets, I thought you might like to practice abstracting the information from a medical record. Please feel free to read the information below and provide the correct diagnostic codes, procedure codes and HCPCS codes. Patient: Jane Jones Date of Birth: 8/29/1960 History of Present Illness: This is an established patient who presents with complaints of a chronic cough, shortness of breath and a low- grade fever for two days. She also states that she has had some chest discomfort and chest congestion. She states she has been having a “very bad cold” for the past two weeks. She had a history of asthma and has been using her rescue inhaler more often in recent days. Past Medical History: The patient has a history of asthma for past 40 years which has been controlled by use of medication. Medications: Flovent inhaler 2x per day, Proventil inhaler 2 puffs every four hours as needed. Physical Examination: This is a well-nourished female in moderate respiratory distress. Neck is supple without palpable masses. Trachea is midline. Chest with faint wheezing on expiration throughout. Pulse ox is at 94% on room air. Examination of the
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HEALTH SCIENCE
NURSING

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