Emergency department Scenarios
Abdominal pain chart
In this we will learn how to code a medical record of Emergency Department scenarios explained with abdominal pain chart.
Patient name: ABC ,Age :53 Date of service :1/2/2018
MRN number: 123456 Physician name: xyz
Chief complaint: Abdominal pain
Hpi(history of present illness):
Patient is coming to Ed for abdomen pain from 2 days which Is burning pain is mainly located in right lower quadrant Pain. Patient has taken some Norco for pain control.
PMH (past medical history):
Personal History: Htn, Diabetes.
Family History: Father is diabetic.
Social history : Former smoker.
ROS(Review of system):
Constitutional Symptoms: weight : 52
Gastrointestinal: Right lower quadrant pain
Constitution: Temp(98F),weight :52
Gastrointestinal: Right lower quadrant tenderness.
- Workup done :
- Urine analysis –Normal
- Whole blood count.
- Radiology :
- Ct abdomen and pelvis
- Final result :
- 3mm stone in right kidney with hydronephrosis
- Intramuscular -injection-morphine
Medical decision making :
As patient is coming with right lower quadrant pain Upon evaluation and based on results from ct findings. Patient had kidney stones with hydronephrosis. Patient Is administered with morphine injection .
- Kidney stone with hydronephrosis .
Old medical records reviewed.
Md physician sign-xyz
- Admission diagnosis: R10.32
- Principal diagnosis: N13.2
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Watch the video of ICD-10 coding part-1 video of above abdominal pain scenario.
Watch the video of CPT coding part-2 video above abdominal pain scenario.