HCS 216 Week 1 Nervous System – Analyzing a Progress Note

Complete the University of Phoenix Material: Nervous System – Analyzing a Progress Note.

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Nervous System – Analyzing a Progress Note

Part 1

Using the following progress note, define the bolded terms within the chart provided.

This patient is being treated in a rehabilitation facility that specializes in neurological disorders.

Progress Note

History of Present Illness: Patient is a 22 y.o. female who was admitted to rehabilitation after an extended stay at University Hospital for treatment of a concussion with no loss of consciousness with subdural hematoma to the frontal lobe and a C1 cervical compression as the result of a motor vehicle accident. She has ongoing complaints of a frontal headache and signs of peripheral neuropathy. There does not appear to be any issue with her memory at this time. An EEG and EMG were performed prior to transfer. Her vital signs have been stable. The patient was admitted to the neurological rehabilitation floor for rehab treatment.

Plan: physical therapy evaluation, occupational therapy evaluation, and speech therapy evaluation.

Impression: concussion with no loss of consciousness, subdural hematoma, CI cervical closed fracture, peripheral neuropathy

Mark Jones Smith, MD

*Do not forget to include the sources for your definitions.

Part 2

Complete the following table using the information in the Impression section of the Progress Note and the Internet. List the appropriate code(s) for the given medical terms and provide a justification explaining why you selected the given medical code(s). An example has been provided for you.