Name at least two reasons why clinicians use a Problem List
What will be an ideal response?
Any two of the following:
Easy to see the active problems for a patient, and also view the history of problems. Most clinical information recorded in the chart are related to one or more problems. Everyone who touches the patient knows what conditions are present.
Problem lists are used to track both acute and chronic conditions.
Helps the clinician to remember to follow up on conditions from previous visits. Maintaining a problem list is a requirement for accreditation by JCAHO.
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Joe Black is an established patient for whom I performed an inguinal hernia repair 3 weeks ago. The hernia repair has a 90-day global period of surgery. His hernia was caused by heavy lifting during a move to his new apartment
Today, Joe presents because of severe headaches, upper left abdominal pain, and heartburn, and he is concerned that he is experiencing a complication from the surgery. Collection of detailed history reveals that the carpet in Joe's new apartment was professionally removed last week because the carpet padding was filled with mold. Performance of detailed physical examination finds sinus congestion, swollen cervical lymph nodes, red conjunctivae, and serous fluid behind left tympanic membrane. Abdominal examination reveals no abnormalities associated with inguinal surgical incision, penis, or testicles. Documentation of low medical decision making shows probability of allergic rhinitis due to mold exposure. Recommend OTC Benadryl, and an immunoglobulin blood test is discussed regarding future allergic reactions. Which of the following best reflects the performed E/M service and modifier usage? a. Office or other outpatient service; established patient; level 3 with modifier 24 b. Office or other outpatient service; established patient; level 4 with modifier 24 c. Office or other outpatient service; established patient; level 3 with modifier 25 d. No E/M service reportable because the visit occurred during the global period of surgery
Which of the following is the best place to perform a physical examination on a six-month-old?
A) the waiting room B) the parent's lap C) an exam table D) the floor
What Medisoft database stores information on each carrier's electronic claim submission requirements?
A. patient data B. provider data C. transactions D. insurance carriers
You have been called to a high school science lab where a male student was splashed in the eye with an alkaline solution. He is complaining of burning to the eye as well as pain. After performing the primary assessment and finding no life-threatening conditions, you would:
A) determine the exact compound the patient was splashed with and the appropriate chemical antidote. B) hold the patient's eye open and begin flushing with large amounts of tap water and continue throughout transport. C) obtain a set of vital signs and determine if the patient is taking medications or has any past medical problems. D) cover both eyes with eye shields and move to the ambulance for immediate transport.