Business > CASE STUDY > him 215 final project.docx Final Project: Coded Patient Record with Rationale Southern (All)

him 215 final project.docx Final Project: Coded Patient Record with Rationale Southern

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him_215_final_project.docx Final Project: Coded Patient Record with Rationale Southern New Hampshire HIM 215: Coding and Classification Systems ICD-10 While reviewing Sally Pire™s chart I loo ... ked in the Diagnoses and Procedures section of the face sheet, and found that her Principal Diagnosis was Acute and chronic Alcoholism. I believe the patients primary diagnosis should be Acute Alcoholism because that is the reason she was admitted into the hospital. While reading the discharge summary and progress notes it is my thought that the secondary diagnosis should be chronic alcoholism. The main terms for her primary diagnosis and secondary diagnosis is alcoholism. Using SelectCoder for her primary diagnosis I entered alcoholism selected the ICD-10-CM tab and three results came up, I decided to try and narrow that down so I entered acute alcoholism and one result came up. The result that came up was F10.22 Alcohol dependence with intoxication so I decided to choose that for my primary code. The secondary diagnosis was chronic alcoholism so I search chronic alcoholism and nothing came up, I then tried again with the terms Alcoholism and three results came up I did not feel that either of the three were what I was looking for so again I changed my search to alcohol dependence since this is an ongoing problem for the patient, this time 26 results came up. I decided to go with F10.220 Alcohol dependence with intoxication, uncomplicated because according to the patients discharge summary and progress no. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [Show More]

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