Deck 10: Admitting a Patient to the Hospital

Question 1

Read and critically analyze the admission H&P for C.H. shown in Figure 10-10. Answer the questions that follow.

-Is this a medical or surgical admission?

Answer 1

Medical

Question 2

Read and critically analyze the admission H&P for C.H. shown in Figure 10-10. Answer the questions that follow.

-The medication listed for this patient is aspirin. Based on the documented PMH, what is the indication for this medication?

Answer 2

Nothing documented in PMH or HPI to indicate why he is taking aspirin, so the indication for it is unknown

Question 3

Read and critically analyze the admission H&P for C.H. shown in Figure 10-10. Answer the questions that follow.

-What additional information should be documented about the medication?

Answer 3

How many milligrams per dose, dosing frequency, route, and indication

Question 4

Read and critically analyze the admission H&P for C.H. shown in Figure 10-10. Answer the questions that follow.

-Do you feel that the information documented in the social history is sufficient? Why or why not?

Question 5

Read and critically analyze the admission H&P for C.H. shown in Figure 10-10. Answer the questions that follow.

-List the systems explored in the ROS and the total number of systems reviewed.

Question 6

Read and critically analyze the admission H&P for C.H. shown in Figure 10-10. Answer the questions that follow.

-Does the ROS meet CMS guidelines for documentation? Why or why not?

Question 7

Read and critically analyze the admission H&P for C.H. shown in Figure 10-10. Answer the questions that follow.

-Do you think the H&P contains enough information to justify hospital admission? Why or why not?

Question 8

Read and critically analyze the admission H&P for C.H. shown in Figure 10-10. Answer the questions that follow.

-Read the assessment section and then the laboratory data section. Identify any additional information that you think should be recorded in the laboratory data section.

Question 9

Read and critically analyze the admission H&P for C.H. shown in Figure 10-10. Answer the questions that follow.

-After reading and critically analyzing the H&P, identify strengths and weaknesses of the document.

Question 10

Read the admission H&P for C.H. shown in Figure 10-10. Write an admit note based on the information documented in the H&P and using the notes in Examples 10.3 and 10.4 as a reference.

Question 11

Read and critically analyze the admission H&P for G.M. shown in Figure 10-11. Answer the questions that follow.
Figure 10-11 Admission H&P for G.M
-Is this a medical or surgical admission?

Question 12

Read and critically analyze the admission H&P for G.M. shown in Figure 10-11. Answer the questions that follow.
Figure 10-11 Admission H&P for G.M
-Review the PMH and identify strengths and weaknesses as documented.

Question 13

Read and critically analyze the admission H&P for G.M. shown in Figure 10-11. Answer the questions that follow.
Figure 10-11 Admission H&P for G.M
-The author states, "10-point review of systems is negative." Identify any information you find in other parts of the document that could be counted as ROS. List the systems reviewed and the total number of systems reviewed.

Question 14

Read and critically analyze the admission H&P for G.M. shown in Figure 10-11. Answer the questions that follow.
Figure 10-11 Admission H&P for G.M
-Based on the discussion of documenting the social history in Chapter 2, what elements could be added to the social history to make it more complete?

Question 15

Read and critically analyze the admission H&P for G.M. shown in Figure 10-11. Answer the questions that follow.
Figure 10-11 Admission H&P for G.M
-The Assessment and Plan portions in this admission H&P is a slightly different format compared with other H&Ps you have seen in this chapter. Do you feel the Assessment and Plan sections, as documented, sufficiently reflect a reason for hospitalization for this patient? Does the H&P meet CMS guidelines for documentation? Why or why not?

Question 16

Read the admission H&P for G.M. shown in Figure 10-11. Using the mnemonic AD CAVA DIMPLS shown in Figure 10-4, write admission orders to reflect the assessment and plan.
A: ______
D: ______
C: ______
A: ______
V: ______
A: ______
D: ______
I: ______
M: ______
P: ______
L: ______
S:______

Question 17

Read the admission H&P for G.M. in Figure 10-11. Write an admit note based on the information documented in the H&P and using the notes in Examples 10.3 and 10.4 as a reference.

Question 18

These abbreviations were introduced in Chapter 10. Beside each, write the meaning as indicated by the con tent of this chapter:
-AD CAVA:
-DIMPLS:
-ADE:
-AMI:
-AP:
-BMP:
-BP:
-BR:
-BRP:
-CAD:
-CBC:
-CC:
-CDSS:
-CMS:
-COPD:
-CPOE:
-CT:
-CVA:
-CXR:
-D5NS:
-ECG:
-ED:
-E/M:
-EMR:
-FH:
-H&H:
-H&P:
-HHS:
-HPI:
-HR:
-HTN:
-I&O:
-IS:
-ISMP:
-IT:
-IV:
-NPO:
-NPSG:
-NS:
-OCR:
-OOB:
-PACU:
-PCA:
-PCP:
-PMH:
-PRN:
-PT:
-RLL:
-ROS:
-RR:
-S/P:
-SH:
-SVN:
-T:
-TID:
-VS:
-WBC:
-WNL: