AStrickland_POAassignment_041424
.docx
keyboard_arrow_up
School
Rasmussen College *
*We aren’t endorsed by this school
Course
HIM1103 SE
Subject
Nursing
Date
Apr 29, 2024
Type
docx
Pages
2
Uploaded by alyssastrickland07 on coursehero.com
Module 02 Assignment - UHDDS: PDX and POA Indicators
Background
:
Review the ICD-10-CM Official Coding Guidelines, Sections II and III for definitions, and Appendix I. Present on Admission Reporting Guidelines (ICD-10-CM Code Book). Use the Present on Admission Indicators provided in the table below.
Present on Admission (POA) Indicator Reporting Options/Definitions:
Y – Yes
Present at the time of inpatient admission
N – No
Not present at the time of inpatient admission
U – Unknown
Documentation is insufficient to determine if the condition is present on admission
Instructions:
Read each scenario and answer the associated questions by applying the coding guidelines and the POA indicators referenced above. Be sure to write your answer beneath each question, using complete sentences, reflecting proper spelling and grammar. All scenarios are inpatient admissions/discharges from a general acute-care hospital.
Scenario 1
A patient presented to the Emergency Room with abdominal pain and bloody diarrhea. Past Medical History indicates a cholecystectomy had been performed one year ago. The patient also has a history of chronic Congestive Heart Failure. At discharge, the provider stated the following diagnoses:
Status post cholecystectomy
Congestive heart failure
Acute diverticulitis
Questions:
1.
Which diagnosis should not be coded?
The diagnosis that should not be coded is post cholecystectomy.
2.
Which diagnosis is most likely the principal diagnosis? The diagnosis that is most likely the principal diagnosis is acute diverticulitis. 3.
Which diagnosis is a comorbid condition?
Congestive heart failure is a comorbid condition. 4.
Which POA indicator would be applied to the acute diverticulitis? The POA would be Y. 5.
Which POA indicator would be applied to the chronic congestive heart failure?
The POA would be Y.
Page 1
of 2
Scenario 2
The patient was admitted to the hospital with fever, cough and shortness of breath. It was noted that the patient has Type II Diabetes on Insulin. After study, the physician could not determine the exact cause of the presenting symptoms. The patient was treated with antibiotics, fluids and received one breathing treatment. During the hospitalization, the patient experienced a nosebleed and a headache. The final diagnosis was stated as “Possible viral pneumonia”.
Questions:
1.
What is the principal diagnosis?
The principal diagnosis would be “possible viral pneumonia”.
2.
Should the coder code the fever, cough and shortness of breath?
Yes, these should be coded as they are the symptoms. 3.
Which POA indicator would be assigned to a diagnosis of “nosebleed”?
The POA would be N. 4.
Which coding guideline under Section II. Selection of Principal Diagnosis would be applied? Specify the Letter Value and the Corresponding Guideline (bold print header only).
H. Uncertain diagnosis.
5.
Should the Type II Diabetes be coded?
No this should not be coded as it is a previous diagnosis. 6.
Which POA indicator would be assigned to a diagnosis of “headache”?
The POA would be N.
Page 2
of 2
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
Related Questions
Case study Analysis:
The nurse is completing the admission assessment for a patient scheduled for cataract surgery in the outpatient center. Having cataract can be common during old age. Because the patient is over the age of 70 and has several chronic conditions, including hypertension and congestive heart failure, the nurse focuses on completing a thorough medication history.
What questions should the nurse include in the medication history? Discuss.
2. How does aging affect drug absorption, metabolism, distribution, and excretion? Explain.
arrow_forward
Question: To the following Given Drugs How to explain the drug's Indication, Side effects, and Health Teaching to the patient that is easier to understand to them?
Given Drug:
Ampicillin 1gm IVTT q6 2
Paracetamol 300 mg IVTT q4
Miconazole 200mg (Monistat) ovule, 1 supp, PV @ HS x 3 days
Title: Care of clients with Human Immunodeficiency Virus
Focus Area: Obstetric Nurse Station
Margerie Ramos, a 32-year-old female, who, on her 34th week of pregnancy was transferred to the hospital after coming from a prenatal clinic and reported to be experiencing continuous regular contractions for almost 2 days. This is her third pregnancy. The labor and delivery team were planning to admit her to observe and monitor her baby through a fetal Non-Stress Test and to exclude complications associated with preterm labor. The patient previously agreed to a scheduled repeat C-section since she already had two prior ones.
Upon admission, the patient verbalized, “I'm cold, I feel so hot.” Temperature…
arrow_forward
Assessment
Topic:- Discuss the role of the nurse in acute care using peer-reviewed literature to support your points.(1400 words)
Instructions
To write an appropriate introduction to the topic
To critically read all six articles when reading to identify the critical points of each article.
Remember to back up your discussion with NMBA codes and standards for practice;
Use the synthesis matrix to assist in combining and developing these key points identified from the critical read of the article into themes
To write an appropriate conclusion to the topic
To provide In-text and end text reference of the article discussed in your essay using correct APA 7 formatting.
arrow_forward
Case Study Link: https://telegra.ph/Case-study-10-09 (Please read it before answering)1. QUESTION:What information systems are implemented by JurongHealth? Describe the input, processing, and output of any one such system.
arrow_forward
Question:
Can you make 1 Goal and 3-5 Objectives Criteria about the case scenario related to the given Nursing Diagnosis?
Also Nursing Interventions with Rationale.
Nursing Diagnosis: Risk for altered growth and development related to the congenital heart defect.
INFANT WITH TETRALOGY OF FALLOT
Case Scenario: Baby Pearl, a 9-month-old girl presents to the emergency department with his mother,who reports episodes of tachypnea, cyanosis, and irritability during feeding. The mother explainsthat these episodes have become more frequent, with baby Pearl becoming more cyanotic aroundthe mouth and fingers especially when crying (tet spells) when she was around 7 months old.These episodes resolve spontaneously but are occurring every few days.
The mother breastfeeds every 3 hours, but sometimes takes a long time to feed. She alsoobserved that baby Pearl becomes diaphoretic with feeding, and stops frequently to catch herbreath while feeding. She reported to the nurse that vomiting the milk…
arrow_forward
Assessor comments:
No comments provided
15. Identify the different types if PPE and the reasons for using each
of the PPE you have identified. Describing the correct practice in the
application, removal and disposal of the said PPE
Type your answer here:
Assessor comments:
No comments provided
H
Save & Refresh
HI
Unit/
Outcomes
Outcome 5
Save & Quit
C
Criteria
ac[5.2] Identify different types of PPE
ac[5.3] Explain the reasons for use of PPE
ac[5.7] Describe the correct practice in the
application and removal of PPE
ac[5.8] Describe the correct procedure for disposal of
used PPE
Cancel
14
13/01/20
arrow_forward
Question:
Can you make 3-5 Goals about the case scenario related to the given Nursing Diagnosis?
Also Nursing Interventions with Rationale.
Nursing Diagnosis: Risk for altered growth and development related to the congenital heart defect.
INFANT WITH TETRALOGY OF FALLOT
Case Scenario: Baby Pearl, a 9-month-old girl presents to the emergency department with his mother,who reports episodes of tachypnea, cyanosis, and irritability during feeding. The mother explainsthat these episodes have become more frequent, with baby Pearl becoming more cyanotic aroundthe mouth and fingers especially when crying (tet spells) when she was around 7 months old.These episodes resolve spontaneously but are occurring every few days.
The mother breastfeeds every 3 hours, but sometimes takes a long time to feed. She alsoobserved that baby Pearl becomes diaphoretic with feeding, and stops frequently to catch herbreath while feeding. She reported to the nurse that vomiting the milk (sometimes goes out…
arrow_forward
Question: To the following Given Drugs How to explain the drug's Indication, Side effects, and Health Teaching to the patient that is easier to understand to them?
Given Drug:
TFD/FTC (Truvada) 300mg tab OD PO
Raltegravir (Isentress) 400mg 1 tab BID PO
Title: Care of clients with Human Immunodeficiency Virus
Focus Area: Obstetric Nurse Station
Margerie Ramos, a 32-year-old female, who, on her 34th week of pregnancy was transferred to the hospital after coming from a prenatal clinic and reported to be experiencing continuous regular contractions for almost 2 days. This is her third pregnancy. The labor and delivery team were planning to admit her to observe and monitor her baby through a fetal Non-Stress Test and to exclude complications associated with preterm labor. The patient previously agreed to a scheduled repeat C-section since she already had two prior ones.
Upon admission, the patient verbalized, “I'm cold, I feel so hot.” Temperature was taken, T=38.5 C. She also…
arrow_forward
Question:
1. Develop a Preventive Program based on the scenario.
Background
Brad is 32 year old male. He was cooking methamphetamine in his kitchen when the substance caught on fire at 2300. The entire house was engulfed in flames when the fire department arrived on scene. The neighbor called 911 when he smelt smoke. Brad was found unconscious by the firefighters and was pulled out. He was stabilized on scene and was rushed to West Hills ED via ambulance. While enroute, the paramedics started an 18 gauge IV in the right C and had Brad on 100% O2 non-rebreather. Paramedics alerted ED of an estimated ETA of 5 minutes. Upon arrival at the ED, Brad was found to have stage 3 burn wounds on his anterior and posterior torso and entire left arm with stage 2 burns on his anterior neck. Brad was at risk for smoke inhalation and a compromised airway, so RT intubated him and fluid resuscitation was initiated.
En Route to Emergency Department
Paramedics alerted the emergency department of…
arrow_forward
Please review the following orders and answer the questions below.
Admit for outpatient observation
Start IV per facility protocol
MS04 2.0 mg IV q 4hrs PRN
CBC, CMP, TS, Coag panel
VS QD, call with out of range
ASA 81 mg chewable QD
Xanax .25 PO TID
Ativan 2.0 mg/d IV
LR 125 mL/hr
Psych consult
List all unapproved abbreviations.
What orders need clarification?
Provide explanation on why those orders need clarification.
arrow_forward
identification of Drugs Used to Treat Diseases of the Blood,Inflammation & Gout
Objective: To familiarize the half-life and recommended dosage of NSAIDS.
Instruction:
1. Supply the missing column accordingly.
HALF-LIFE (in hours)
Recommended Dosage
DRUG
1: Aspirin
2. Naproxen
3. Ibuprofen
4. Celecoxib
5. Ketoprofen
6.
Indomethacin
7. Sulindac
8. Ketorolaс
9. Salicylate
arrow_forward
- Invitation: NUR X
Case Study Assignment #11
len.instructure.com/courses/153/assignments/288?module_item_id=1737
> Assignments
1
vious
Case Study Assignment #11
Due: Wed Oct 11, 2023 3:59pm
Attempt 1
x +
In Progress
NEXT UP: Submit Assignment
Unlimited Attempts Allowed
Available: Oct 3, 2023 10:00pm until Oct 11, 2023 9:59pm
Choose a submission type
↑
1
Upload
Office 365
:
More
E
Q Search
WW
Details
The student is assigned a case study to complete a nursing care plan. The student must complete a holistic assessment and establish priorities based on the client's needs. The entire nursing process should be framed to
illustrate the student's understanding of the eight (8) areas of the client's needs and life considerations in accordance with integrated processes.
CASE STUDY SICKLE CELL ANEMIA 10042023-1.pdf
9.9
1.
G
ZU
85 A
A
30
13
10 Possible Points
Submit Assignment Next>
40
6
400 PM
10/7/2023
ecert
Add Comment
@ •
SA
Connert wa
az
SANT
WA
O
arrow_forward
Question:
Can you make 1 Goal with 3-5 Objectives about the case scenario related to the given Nursing Diagnosis?
Also Nursing Interventions with Rationale.
Nursing Diagnosis: Risk for altered growth and development related to the congenital heart defect.
INFANT WITH TETRALOGY OF FALLOT
Case Scenario: Baby Pearl, a 9-month-old girl presents to the emergency department with his mother,who reports episodes of tachypnea, cyanosis, and irritability during feeding. The mother explainsthat these episodes have become more frequent, with baby Pearl becoming more cyanotic aroundthe mouth and fingers especially when crying (tet spells) when she was around 7 months old.These episodes resolve spontaneously but are occurring every few days.
The mother breastfeeds every 3 hours, but sometimes takes a long time to feed. She alsoobserved that baby Pearl becomes diaphoretic with feeding, and stops frequently to catch herbreath while feeding. She reported to the nurse that vomiting the milk…
arrow_forward
SEE MORE QUESTIONS
Recommended textbooks for you
Understanding Health Insurance: A Guide to Billin...
Health & Nutrition
ISBN:9781337679480
Author:GREEN
Publisher:Cengage
Related Questions
- Case study Analysis: The nurse is completing the admission assessment for a patient scheduled for cataract surgery in the outpatient center. Having cataract can be common during old age. Because the patient is over the age of 70 and has several chronic conditions, including hypertension and congestive heart failure, the nurse focuses on completing a thorough medication history. What questions should the nurse include in the medication history? Discuss. 2. How does aging affect drug absorption, metabolism, distribution, and excretion? Explain.arrow_forwardQuestion: To the following Given Drugs How to explain the drug's Indication, Side effects, and Health Teaching to the patient that is easier to understand to them? Given Drug: Ampicillin 1gm IVTT q6 2 Paracetamol 300 mg IVTT q4 Miconazole 200mg (Monistat) ovule, 1 supp, PV @ HS x 3 days Title: Care of clients with Human Immunodeficiency Virus Focus Area: Obstetric Nurse Station Margerie Ramos, a 32-year-old female, who, on her 34th week of pregnancy was transferred to the hospital after coming from a prenatal clinic and reported to be experiencing continuous regular contractions for almost 2 days. This is her third pregnancy. The labor and delivery team were planning to admit her to observe and monitor her baby through a fetal Non-Stress Test and to exclude complications associated with preterm labor. The patient previously agreed to a scheduled repeat C-section since she already had two prior ones. Upon admission, the patient verbalized, “I'm cold, I feel so hot.” Temperature…arrow_forwardAssessment Topic:- Discuss the role of the nurse in acute care using peer-reviewed literature to support your points.(1400 words) Instructions To write an appropriate introduction to the topic To critically read all six articles when reading to identify the critical points of each article. Remember to back up your discussion with NMBA codes and standards for practice; Use the synthesis matrix to assist in combining and developing these key points identified from the critical read of the article into themes To write an appropriate conclusion to the topic To provide In-text and end text reference of the article discussed in your essay using correct APA 7 formatting.arrow_forward
- Case Study Link: https://telegra.ph/Case-study-10-09 (Please read it before answering)1. QUESTION:What information systems are implemented by JurongHealth? Describe the input, processing, and output of any one such system.arrow_forwardQuestion: Can you make 1 Goal and 3-5 Objectives Criteria about the case scenario related to the given Nursing Diagnosis? Also Nursing Interventions with Rationale. Nursing Diagnosis: Risk for altered growth and development related to the congenital heart defect. INFANT WITH TETRALOGY OF FALLOT Case Scenario: Baby Pearl, a 9-month-old girl presents to the emergency department with his mother,who reports episodes of tachypnea, cyanosis, and irritability during feeding. The mother explainsthat these episodes have become more frequent, with baby Pearl becoming more cyanotic aroundthe mouth and fingers especially when crying (tet spells) when she was around 7 months old.These episodes resolve spontaneously but are occurring every few days. The mother breastfeeds every 3 hours, but sometimes takes a long time to feed. She alsoobserved that baby Pearl becomes diaphoretic with feeding, and stops frequently to catch herbreath while feeding. She reported to the nurse that vomiting the milk…arrow_forwardAssessor comments: No comments provided 15. Identify the different types if PPE and the reasons for using each of the PPE you have identified. Describing the correct practice in the application, removal and disposal of the said PPE Type your answer here: Assessor comments: No comments provided H Save & Refresh HI Unit/ Outcomes Outcome 5 Save & Quit C Criteria ac[5.2] Identify different types of PPE ac[5.3] Explain the reasons for use of PPE ac[5.7] Describe the correct practice in the application and removal of PPE ac[5.8] Describe the correct procedure for disposal of used PPE Cancel 14 13/01/20arrow_forward
- Question: Can you make 3-5 Goals about the case scenario related to the given Nursing Diagnosis? Also Nursing Interventions with Rationale. Nursing Diagnosis: Risk for altered growth and development related to the congenital heart defect. INFANT WITH TETRALOGY OF FALLOT Case Scenario: Baby Pearl, a 9-month-old girl presents to the emergency department with his mother,who reports episodes of tachypnea, cyanosis, and irritability during feeding. The mother explainsthat these episodes have become more frequent, with baby Pearl becoming more cyanotic aroundthe mouth and fingers especially when crying (tet spells) when she was around 7 months old.These episodes resolve spontaneously but are occurring every few days. The mother breastfeeds every 3 hours, but sometimes takes a long time to feed. She alsoobserved that baby Pearl becomes diaphoretic with feeding, and stops frequently to catch herbreath while feeding. She reported to the nurse that vomiting the milk (sometimes goes out…arrow_forwardQuestion: To the following Given Drugs How to explain the drug's Indication, Side effects, and Health Teaching to the patient that is easier to understand to them? Given Drug: TFD/FTC (Truvada) 300mg tab OD PO Raltegravir (Isentress) 400mg 1 tab BID PO Title: Care of clients with Human Immunodeficiency Virus Focus Area: Obstetric Nurse Station Margerie Ramos, a 32-year-old female, who, on her 34th week of pregnancy was transferred to the hospital after coming from a prenatal clinic and reported to be experiencing continuous regular contractions for almost 2 days. This is her third pregnancy. The labor and delivery team were planning to admit her to observe and monitor her baby through a fetal Non-Stress Test and to exclude complications associated with preterm labor. The patient previously agreed to a scheduled repeat C-section since she already had two prior ones. Upon admission, the patient verbalized, “I'm cold, I feel so hot.” Temperature was taken, T=38.5 C. She also…arrow_forwardQuestion: 1. Develop a Preventive Program based on the scenario. Background Brad is 32 year old male. He was cooking methamphetamine in his kitchen when the substance caught on fire at 2300. The entire house was engulfed in flames when the fire department arrived on scene. The neighbor called 911 when he smelt smoke. Brad was found unconscious by the firefighters and was pulled out. He was stabilized on scene and was rushed to West Hills ED via ambulance. While enroute, the paramedics started an 18 gauge IV in the right C and had Brad on 100% O2 non-rebreather. Paramedics alerted ED of an estimated ETA of 5 minutes. Upon arrival at the ED, Brad was found to have stage 3 burn wounds on his anterior and posterior torso and entire left arm with stage 2 burns on his anterior neck. Brad was at risk for smoke inhalation and a compromised airway, so RT intubated him and fluid resuscitation was initiated. En Route to Emergency Department Paramedics alerted the emergency department of…arrow_forward
- Please review the following orders and answer the questions below. Admit for outpatient observation Start IV per facility protocol MS04 2.0 mg IV q 4hrs PRN CBC, CMP, TS, Coag panel VS QD, call with out of range ASA 81 mg chewable QD Xanax .25 PO TID Ativan 2.0 mg/d IV LR 125 mL/hr Psych consult List all unapproved abbreviations. What orders need clarification? Provide explanation on why those orders need clarification.arrow_forwardidentification of Drugs Used to Treat Diseases of the Blood,Inflammation & Gout Objective: To familiarize the half-life and recommended dosage of NSAIDS. Instruction: 1. Supply the missing column accordingly. HALF-LIFE (in hours) Recommended Dosage DRUG 1: Aspirin 2. Naproxen 3. Ibuprofen 4. Celecoxib 5. Ketoprofen 6. Indomethacin 7. Sulindac 8. Ketorolaс 9. Salicylatearrow_forward- Invitation: NUR X Case Study Assignment #11 len.instructure.com/courses/153/assignments/288?module_item_id=1737 > Assignments 1 vious Case Study Assignment #11 Due: Wed Oct 11, 2023 3:59pm Attempt 1 x + In Progress NEXT UP: Submit Assignment Unlimited Attempts Allowed Available: Oct 3, 2023 10:00pm until Oct 11, 2023 9:59pm Choose a submission type ↑ 1 Upload Office 365 : More E Q Search WW Details The student is assigned a case study to complete a nursing care plan. The student must complete a holistic assessment and establish priorities based on the client's needs. The entire nursing process should be framed to illustrate the student's understanding of the eight (8) areas of the client's needs and life considerations in accordance with integrated processes. CASE STUDY SICKLE CELL ANEMIA 10042023-1.pdf 9.9 1. G ZU 85 A A 30 13 10 Possible Points Submit Assignment Next> 40 6 400 PM 10/7/2023 ecert Add Comment @ • SA Connert wa az SANT WA Oarrow_forward
arrow_back_ios
SEE MORE QUESTIONS
arrow_forward_ios
Recommended textbooks for you
- Understanding Health Insurance: A Guide to Billin...Health & NutritionISBN:9781337679480Author:GREENPublisher:Cengage
Understanding Health Insurance: A Guide to Billin...
Health & Nutrition
ISBN:9781337679480
Author:GREEN
Publisher:Cengage