HCS 214 Week 5 Urinary System–Analyzing a Progress Note

Complete the University of Phoenix Material: Urinary System-Analyzing a Progress Note.

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Urinary System – Analyzing a Progress Note

Part 1

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

This patient is a resident in a Nursing Home and is being assessed by a local doctor.

Progress note:

Patient is a 68 y.o. male with history of kidney stones, urinary tract infection (UTI) and diabetes insipidus. Nursing staff reports a change in mental status, foul smelling urine, and increased incontinence with complaints of pain with urination.

On examination patient is alert. Patient notes having increased pain with urination and burning along with extreme pain in the lower abdomen at times. A urine culture was positive for e-coli bacteria. The urinalysis is positive for WBCs, RBC, and increased pH with results favorable for stone formation.

Plan to start Macrobid, increase fluid intake, repeat urinalysis and kidney function in the morning. Please catheterize the patient. Portable ultrasound in am. If positive will discuss possible cystoscopy and nephrology referral.

Impression: UTI, kidney stone

1. George, M.D.

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

Part 2

Using the information in the progress note, decide which code correctly represents the diagnosis. Underline the code of your choice.

References

Centers for Medicare & Medicaid Services (23 Oct. 2014). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.” Retrieved from

https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx