The patient is a 23 y/o male who presents with a fracture of the femoral shaft after a wooden beam fell on him while he was working.

For each of the following 5 progress notes, indicate if the medical documentation is complete. If the documentation is considered not complete, indicate what the provider needs to complete for an accurate code to be selected. 

The patient is a 23 y/o male who presents with a fracture of the femoral shaft after a wooden beam fell on him while he was working. An open reduction with internal fixation (ORIF) was performed to correct the fracture using an intramedullary rod. Post-operatively on day three, the patient was pale, and labs demonstrated an RBC of <4.0. The patient is presumed to be anemic.

Is this medical documentation complete? 

If no, what documentation does the provider need to complete for an accurate code to be selected?

The patient is a 13 y/o female who presents to the physician’s office with a fever, cough, and chest crackling. The patient becomes hypoxic while in the office and is then admitted to the inpatient facility with acute respiratory failure. The patient is maintained on ventilation for three days, still hypoxic, with lab work demonstrating bacterial growth of klebsiella pneumoniae. At day five, the patient is much improved and determined stable for discharge with a final diagnosis of bacterial pneumonia.

Is this medical documentation complete? 

If no, what documentation does the provider need to complete for an accurate code to be selected?

The patient is a 17 y/o male presenting to the inpatient facility for the third round of chemotherapy treatment. The patient is immunocompromised due to the chemotherapy and began IV rehydration during the first day of treatment. The patient finishes treatment on day three and is discharged with MiraLAX for constipation, which was experienced during the admission.

Is this medical documentation complete? 

If no, what documentation does the provider need to complete for an accurate code to be selected?

The patient is a 55 y/o male who presents to the ED due to having symptoms of dizziness, shaking, and a fast heartbeat. The patient has type two diabetes and is well-controlled with insulin. After evaluation, it is determined that the patient is experiencing a mild hypoglycemic episode and is treated with IV fluids and juice. The patient is monitored for two hours and sent home with a scheduled follow-up one week from the date.

Is this medical documentation complete? 

If no, what documentation does the provider need to complete for an accurate code to be selected?

The patient is a 60 y/o male with CKD and diabetes with COPD. The patient is admitted due to an exacerbation of his COPD due to rhinovirus infection and is managed with respiratory support and monitoring of his other chronic conditions. During admission, a discovery of elevated blood pressure is made, and he is started on lisinopril. On day four, the patient is discharged with directions to manage his condition and return for a two-week follow-up.

Is this medical documentation complete? 

If no, what documentation does the provider need to complete for an accurate code to be selected?