diagnosis procedure codes

severity
location
chronic vs acute onset
clinical concepts- Scribe what we saw
clinical impression- Doctor disposition speccfyic spesific final diagnosis
type IDM NISDM systolic fx rheumatic transverse spiral
onset acute chroninc acute on chronic reccurnt

risk factors
severity-mild moderate severe, stage
location laterality rght or left
associted sx appendicitis fever,nausea, vomiting
----------------------------------specific and supported
too general non spesific
lack supporting documentation unsupported
----------------------------------------------1.procedure diagnosis
2. risk factor,onset, associated sx, severity
3.too general, lack supporting
4. onset type associated sx
5. true
6. box 1
assoiated sx
box 2 location
box 3 onset
box 4
type
7. box 1
onset box 2 associated
box 3
type
box 4 seve
rity
8. international classification of diaseases
9. box 1
clinical condition
box 2 clinical impression
b
ox 3
squaela
box 4 clinical concepts
10. outdated non specifidity
11.10/01/2015
12. true
13 unspecied
14. ......lesser diagnosis
15. onset
16. box 1 type box 2 onset box 3 risk factors box 4 location severity
box 5
associated sx
17. right left
18. specific and supported
19. outside the patients room
20. severe
-------------------------------------------------------Emergency medicine
condition-general
impression- spesific

concept documentation

onset acute chronic location

risk factor Irritayndrome
ble nowl s
appendicitis
type onset associted sx
backpain
onset risk factors severity location associated sx
CP
type risk factor location associated sx
CAD
Onset risk factors location assoicated sx
cholelithaiasis
type onset risk factors severity location assoated sx
CHF
type onset associated sx
colles' fx
type location episode
gustillo lasification grade 1 2 3
9. HA
type onset location risk factors severity associated sx
10 Ottistis media tpe onset location risk factors

Emergency exam
1. appendicitis
2. risk factors
3...the patient has CABG
4. acute, atraumatic lumpar puncture
5. type
6. specific and supported
7. about 50
8. associated sx
9. ance exiting the room (B)

10.
11.
12.
13.
14.
15.

(D)
the number of times ...has been evaluated for this clinical condition
True
because 2 similar.....
did not improve with tx
true