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Comprehensive H&P for C.G.
AcomprehensiveH&PforpatientC.G.isshown.C.G.isanewpatientpresentingtoaninternalmedicineoffice-based practice. Suzette Barnes, an experienced nurse practitioner, authored the H&P. As you read it, keep in mind the requirementssetforthinthe1997GuidelinesofDocumentationforEvaluationandManagementbyCMSforinformation thatshouldbeincludedinamedicalrecord.RefertotheH&Ptoanswerthequestionsthatfollow.
L Does this document meet the CMS guidelines for documentation of a comprehensive H&P? Why or why not?
2.    Critically analyzetheH&Pandlistanyerrors.IdentifythestrengthsoftheH&P.
3.   DidanyquestionscometomindthatyouareunabletoanswerafterreadingtheH&P?
4.. Are the conditions listed in the Assessment section reasonably supported by the history? Wny or why not?
s. Did you identify other differentialdiagnoses or cconditions that could be included in the assessment? If so, list
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&.List the ICD-10 code for each of the following.
Weightloss:         .::;,,;:.:.;..                            _
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Graves disease:
Migraineheadache:Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â _
Anxiety:Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â
7.  WoulditbeappropriatetoincludetheIC().10codeforGravesdiseasewhenbillingforthisvisit?Whyorwhynot?
a.   Istheplanreasonable basedontheassessmentslisted?Whyorwhynot?
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Comprehensive H&P for D. A.
Tyler Martin, a third-year medical student on a family practice clerkship, was directed to obtain a comprehensive H&P of a new patient: D. A. D. A. recently moved to your city and has never been seen at this practice. She comes in today  to  establish care, and she is complaining of a cough. Followingis the student’s documentation of the comprehensive H&P. As you read it, keep in mind the requirements set forth in the 1997 Guidelines of Documentation for Evaluation and Management by CMS for information that should be included in a medical record. Refer to  the  H&P to  answer  the questions thatfollow.
1.     DoesthisdocumentmeettheCMSguidelinesfordocumentationofacomprehensiveH&P?Whyorwhynot?
2.     CriticallyanalyzetheH&Pandlistanyerrors.
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3.   Didanyquestionscome tomindthatyouareunabletoanswerafterreadingtheH&P?
4.   ArethediagnoseslistedintheAssessmentsectionreasonablysupportedbythehistory?Whyorwhynot?
s. Did you identify other differential diagnoses or conditions that could be included in the assessment? If so, list.
6. Is the plan reasonable based on the assessments listed? Why or why not?
SCIENCE
HEALTH SCIENCE
NURSING
