- Description
HCS 216 Week 3 Musculoskeletal System – Analyzing a Progress Note
Complete the University of Phoenix Material: Musculoskeletal System – Analyzing a Progress Note.
Click the Assignment Files tab to submit your assignment.
Musculoskeletal 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 local outpatient physical therapy office.
Progress Note
Patient is a 55 y.o. male who returns for session 3/10 outpatient therapy.
History: Patient has a history of arthritis (unspecified) to the cervical spine, fibromyalgia, and osteoarthritis. Patient is 4 weeks post-operative right femur surgery following a greenstick fracture after falling on the ice. Patient had a post-operative MRI last week. Report attached.
Subjective: The patient states his pain is moderate level 4/10. He notes his function is improving and he is now ambulating with a cane.
Strength:
Adduction: 2/3
Abduction: 2/2
Knee extension: 2/2 painful
Knee flexion: 3/2 painful
Plan: Continue with physical therapy sessions as per plan.
Diagnosis: Femur shaft fracture
Julie Brush, PT
*Do not forget to include the sources for your definitions.
Medical term | Definition | Sources |
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Part 2
Complete the following table using the information found in 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).
Medical term | Medical code | Justification | Sources |
Femur shaft fracture (stress fracture, unspecified femur) | |||
Rheumatoid Arthritis unspecified | |||
Osteoarthritis (Polyosteoarthritis unspecified) |