Physician Query Assignment
Please pick one of these scenarios below and write a physician query. For examples on how to write a physician query please see AHIMA article at: http://journal.ahima.org/2013/02/01/physician-query-examples/
Scenario #1
A patient is admitted for a right hip fracture. The H&P notes that the patient has a history of chronic congestive heart failure. A recent echocardiogram showed left ventricular ejection fraction (EF) of 25%. The patient’s home medications include metoprolol XL, lisinopril, and Lasix.
Scenario #2
A patient is admitted with chest pain radiating through to his middle back. The provider orders multiple tests to rule out cardiac diagnoses which are all ruled out. On day 2 of the stay, the provider orders the head of the bed to be raised, no coffee or fatty foods, and a 20 mg dose of omeprazole daily. On day 4, the patients symptoms subside and he is discharged home. There is no diagnosis documented by the provider.
Scenario #3
Patient is admitted with pneumonia. The admitting H&P exam reveals WBC of 14,000; a respiratory rate of 24; a temperature of 102 F; heart rate of 120; hypotension; and altered mental status. The patient is administered an IV antibiotic and IV fluid resuscitation.
Scenario #4
In the impression of the pathology report ovarian cancer is documented; however, only ovarian mass is documented in the final discharge statement by the provider.
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