HCS 216 Week 4 Reproductive System – Analyzing a Progress Note

0 items
HCS 216 Week 4 Reproductive System – Analyzing a Progress Note
HCS 216 Week 4 Reproductive System – Analyzing a Progress Note
$6.99
  • Description

HCS 216 Week 4 Reproductive System – Analyzing a Progress Note

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

Click the Assignment Files tab to submit your assignment.

Reproductive System – Analyzing a Progress Note

Part 1

 

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

 

This patient is being assessed in the office by her OB-GYN.

 

Progress Note

 

Patient is a 25 y.o. female that presents for treatment of endometriosis. She has severe dysmenorrhea with an abnormal menstrual cycle for 3 years. There is a history of one pregnancy which was ectopic which did not require removal of the fallopian tubes. An ultrasound of the ovaries was performed 1 month prior to rule out ovarian cysts which was negative. Pregnancy test is negative.

 

Plan: repeat ultrasound, estradiol and progesterone levels. Will discuss possibility of uterine biopsy and surgical referral.

 

Impression: endometriosis

 

James Jones DO

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

Medical term

Definition

Sources

1.

  

2.

3.

4.

5.

6.

7.

8.

9.

10.

 

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 termMedical codeJustificationSources
Endometriosis,

unspecified

   
Dysmenorrhea,

unspecified

   
Ectopic pregnancy, other