Scenario E (Questions 21-24): \"A 79-year-old female was admitted with acute sho

Question

Scenario E (Questions 21-24): "A 79-year-old female was admitted with acute shortness of breath and the patient also carries a diagnosis of CHF and COPD. The emergency room physician suspected pneumonia but this was ruled out. The consulting physician felt that the patient’s symptoms were ‘more heart failure related’; however, the progress note on 7/9/09 at 0830 hours by the attending physician noted that he did not feel the shortness of breath was related to congestive heart failure due to lack of clinical findings. The final progress note on 7/9 by the Heart Failure Clinic states that the shortness of breath was due to volume overload.” 21. What were the documented diagnoses? Check all that apply: ?Acute SOB ?CHF ?Pneumonia ?COPD 22. Which of the diagnoses is/are symptom(s)? Check all that apply: ?Acute SOB ?CHF ?Volume overload ?COPD 23. What additional information is documented about the diagnoses? Check all that apply: ?Pneumonia ruled out ?Heart failure ?Conflicting statements that SOB was not related to CHF ?SOB was due to volume overload 24. What missing information prevents the inpatient coder from coding to the highest level of specificity? Check all that apply: ?Underlying cause of SOB ?Underlying cause of pneumonia ?Underlying cause of COPD ?Underlying cause of volume overload

Explanation / Answer

21. The documented diagnosis is of CHF and COPD because these were the two diagnosis carried by the patient when admitted. Acute SOB was considered as well.

22. Symptoms are Acute SOB rest all are disease which consists of symptoms.

23. That SOB was due to volume overload and no other causes were identified.

24. Underlying cause of volume overload is missing which makes the diagnosis no specific because it could be due to many reasons.

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