Question 1
Which of the following is NOT a subjective medical history question?
◦ What is your date of birth?
◦ What prescription medications are you currently taking?
◦ What were you doing when the problem was first experienced?
◦ What over-the-counter medications are you currently taking?
Question 2
OFFICE VISIT
S: This established patient comes in stating that her legs are swollen and tender to touch. She has had a little bit of shortness of breath and just has not been feeling normal. PAST MEDICAL HlSTORY: Congestive heart failure, hypertension, and gastritis. MEDICATlON: Warfarin, potassium, Lasix, Clonapam, metoprolol, Dilantin, and orneprazole. ALLERGIES: PENICILLIN.
O: VITAL SIGNS: As noted. O
2 saturations 88%. GENERAL: Alert and oriented. HEENT: Unremarkable. LUNGS: There are a few crackles in the lungs. HEART: Regular rate and rhythm. EXTREMITIES: There is 2+ edema. LABORATORY/DIAGNOSTIC: Normal CBC. Comprehensive panel shows a BUN that is slightly elevated, otherwise unremarkable. Her BNP is high at 442.
A: Congestive heart failure, peripheral edema
P: We will have her double up her Lasix taking 2 a day and potassium 2 per day for the next 5 days and then go back to her regular medications. If she is still having swelling problems, she is to let us know.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
The nurse needs to note the source of the patient health history
Patient Teaching
Example of problem focused patient
Regular staff meetings increase the efficiency of the medical office staff.
A medical assistant assists with minor surgery performed in the medical office.
Symptoms of a patient in shock.