QSEN
DiscussionThis week we will try our hand at using ICD-10 to code a patient interaction.?To begin, think of one patient you provided care for in the past month. Find the codes that appropriately fit the patient's presentation by accessing the website: . Do not put anything about the patient in the text box, just the codes that represent the patient’s presentation.?For example, your post may look like this:B39.9 E11 Z79.84 I10 For the above example, I could draw the conclusion that the patient presented with histoplasmosis symptoms such as coughing, chest pain and/or shortness of breath and has a history of Type 2 Diabetes (already on anti-diabetic medication so this is not new) and has a blood pressure over 140/80 (definition given for essential hypertension).?The rest of the class will then try to figure out how the patient presented, what the patient looked like, differential diagnosis, or what might be ordered. Essentially creating a case study from the coding.?This works like a backward puzzle.?When you follow each code using the links you can get a definition of the diagnosis as well as inclusion and exclusion criteria. When responding to another’s post, try linking interventions and outcomes to the case. Use the nursing language system linked below to help guide your response. Nursing Intervention Classifications/Nursing Outcome Classifications (NIC/NOC) are the most commonly used since they link interventions?with outcomes. You can view standardized nursing language systems through the following links: Discussion Rubric 10 pts42-30-1Use of ICD-10 CodesProvides ICD-10 codes that reflect a patient encounter.Provides ICD-10 codes that are questionable in representing a patient encounterProvides one to two ICD-10 codes that do not reflect a patient encounter 31-20Response to OthersPosts responses to two classmates. Links the patient encounter to interventions. Provides a clear description of the patient presentationPosts responses to two classmates. Includes some characteristics of a substantive post (refer to syllabus). Description of the patient presentation is missing some aspect from the coding.Posts responses to two classmates. Postings do not meet substantive guidelines (refer to syllabus). Does not link the codes to the patient encounter. Does not provide interventions.31-20Initial and/or response postingsInitial posts and responses are on time. Late postings OR responds to less than the minimum number of posts by others Late post, responds to less than the minimum number of posts, initial ................
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