Comprehensive H&P Case Study Questions

Answer

1. • 1. Comprehensive History and Physical (H&P)

        Question 1: The CMS Guidelines for Documentation of a Comprehensive History and Physical (H&P)

        A comprehensive medical history and physical assessment (H&P) is conducted to determine whether there are underlying factors in the overall condition that would compromise the quality of the planned surgery (Gaffney, Hatcher, Milligan, & Trickey, 2016). Among the key elements to assess include allergies to specific medications or any developing or existing co-morbid condition that necessitates additional interventions to reduce medical risks or adverse events. Based on the CMS guidelines for documentation of a comprehensive history and physical, this document meets all the requirements. It details all provisions concerning the patient's chief complaints, the current sickness, appropriate history relevant to the age of the patient, drugs, and possible allergies (Gaffney, Hatcher, Milligan, & Trickey, 2016). If also offers assessments of the body system, including heart and lungs, impression, and a practical plan of care to help the patient.

        Question 2: Strengths and Errors of the H&P

        The H&P is comprehensive enough as it details all H&P requirements when assessing patients before admission for a surgical procedure. The US Department of Health and Human Services (DHHS) (2011) highlights all elements, including the history of ailments and the patient's current health status, allowing care providers to take in precautions to avoid the occurrence of healthcare events. However, the H&P does not provide a comprehensive plan to meet the patient's underlying conditions' care demands.

        Question 3

        Several questions came to mind that I was unable to answer after reading the H&P. For instance, in this scenario, does an H&P work before or after visiting the Emergency Department for procedures? The medical documentation of the patient should be presented before the commencement of a medical surgery to detect any changes in patient’s health status from the time the H&P was conducted. However, the chief complaint of the patient is a follow-up process after a visit to the Emergency Department. Prior visits help practitioners update the patient's assessment details and detect any changes upon examination or after a surgical procedure.

        Question 4

        The patient’s history reasonably supports the conditions listed in the assessment section. The assessment reports moderate persistent asthma with (acute) exacerbation, pneumonia, unspecified organism, essential (primary) hypertension, unspecified hyperlipidemia, obesity, and hypertension. Anne Smith’s parents were diagnosed with inheritable cardiovascular disease. All these conditions are risk factors for CV disease, with high blood pressure or hypertension being the most significant risk factor. The patient has an unhealthy bodyweight that suggests the likelihood of high cholesterol levels. The vulnerability to chronic conditions increases as the amount of body cholesterol also advances. As an older woman of 55years with a high body mass, Anne is likely to suffer from hypertension and obesity. From the assessment, the patient also suffers hyperlipidemia. In this case, hyperlipidemia would be associated with blood containing excessive fats and lipids such as glycerides and cholesterol, which increases fatty acids present in arteries and the danger of blockages. The patient’s history suggests that Anne is an obese Caucasian female implying that her blood system contains excessive fatty lipids that are detrimental to health.

        Question 5:

        Among the other differential diagnoses and conditions that should be included in the assessment include; type 2diabetes and high blood cholesterol. 

        Question 6: the ICD-10 Codes

        • Moderate persistent asthma with (acute) exacerbation: J45.51
        • Pneumonia, unspecified organism:  J18.9
        • Essential (primary) hypertension: I10
        • Hyperlipidemia, unspecified: E78.5
        • Obesity: E66

        Question 7:

        It is appropriate to include the ICD-10 code for pneumonia when billing for this visit because although the organism causing the condition is unspecified, antibiotics are necessary. Antibiotics help to track the specific bacterium type resulting in an infection. A doctor should also recommend over-the-counter drugs such as naproxen to ease aches and pains and reduce likely fevers. Although these options are available, antibiotics should be billed to help in clearing the infection completely.

         

        Question 8: Is the plan reasonable based on the assessments listed? Why or why not?

        The plan is not reasonable based on the assessments listed. The care plan should detail clearly how it will meet the medication needs of every condition, and whether or not the conditions have alternatives in terms of management.

        Question 9: Patient Education Strategies

        • It is vital to understand the unique needs of patients when selecting the most effective patient education technique. Before introducing any patient education strategies, clinicians must assess the patient's current level of knowledge because any educational approaches will be useless if the patient lacks adequate functional health literacy (World Health Organization, 2005). Basing on the patient’s history details, Anne retired from clerical work, meaning she can acquire, process, and understand necessary health information required for making appropriate health decisions (Gaffney, Hatcher, Milligan, & Trickey, 2016). Equipping a patient with adequate knowledge and understanding concerning their health condition is the most promising way of sparking patient activation.
        • The other strategy is to offer educational materials in patient-preferred formats, from paper handouts to digital technologies. However, in this case, clinicians will work with Anne to assess the exact option that meets their preferences. The most efficient strategies of educating this patient concerning her health and how to use the medication would be one-on-one teaching, demonstrations, YouTube videos, posters, and trained peer educators. Clinicians must consider how patients learn best and pick the most feasible option to integrate into patient lifestyles.
        • Thirdly, care providers should lean on health technology to access and store their educational materials with convenience. Through the online interface, Anne can access her portal and access her lab results, histories, discussions, dosage details, and other health information (World Health Organization, 2005). Clinicians can engage in OpenNotes to remind Anne of the data to boost their understanding of the medications and the exact dosages to take. As a patient, she can forget 80% of what her doctor advises, and OpenNotes are relevant. They will remind her of this information and engage with care providers concerning potential treatment issues.

        Question 10: Health Promotion Recommendations from AHRQ according to age/gender/conditions

        • Clinicians should advise Anne on healthy living by promoting healthy eating habits. This includes consuming healthy, low-fat, and high-fiber foods such as vegetables and fruits, minimally processed foods, healthful sources of protein such as fish, beans, poultry-, refined grains, and healthy fats as nuts (Batsis & Zagaria, 2018). A nutritionist can work collaboratively with the clinicians to suggest the best meal plans for Anne.
        • A healthy diet should incorporate frequent exercises, and Anne can engage in long walks, a bit of jogging, and stretching to increase body flexibility. Obese patients are required to switch to the fitness world to reduce cholesterol levels by preventing fat accumulation in the blood (Batsis & Zagaria, 2018). Anne should be assigned to a certified trainer who will help her keep fit and recommend the best activities that suit her age.
        • As an elderly patient, Anne requires home nursing care to help monitor her health progress and flexibility in taking the recommended medication (Batsis & Zagaria, 2018). She also requires support and love from her family, who can also offer close monitoring of her progress and report on any critical health issue that develops.