UPX Material - University of Phoenix
University of Phoenix Material
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, C1 cervical closed fracture, peripheral neuropathy
Mark Jones Smith, MD
*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 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.
|Medical term |Medical code |Justification |Sources |
|Example: Concussion with no|S06.0X0 |There are a variety of | |
|loss of consciousness | |codes to choose from; | |
| | |however, S06.0X0 was the | |
| | |code that detailed ‘with no| |
| | |loss of consciousness.’ | |
| | |This code was chosen | |
| | |because there was not | |
| | |enough detail provided to | |
| | |narrow it down to another | |
| | |code such as S06.0X1A | |
| | |(Concussion with loss of | |
| | |consciousness of 30 minutes| |
| | |or less.) | |
|Subdural hematoma | | | |
|(Nontraumatic subdural | | | |
|hemorrhage, unspecified) | | | |
|C1 cervical closed fracture| | | |
|(Unspecified displaced | | | |
|fracture of first cervical | | | |
|vertebra, initial encounter| | | |
|for closed fracture) | | | |
|Peripheral neuropathy | | | |
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