Reference no: EM133875146

Question

1. A 64-year-old female is admitted to the hospital with nausea, vomiting, and edema. Lab values indicate the patient has dehydration. The patient takes lisinopril as prescribed along with levothyroxine for hypothyroidism. On the discharge summary, the final diagnoses of acute renal failure, hypothyroidism, and dehydration are documented. What discrepancy should a coding professional note in this documentation?

There is not enough detail in the documentation to assign the dehydration. There is no explanation for the patient's vomiting. There is no correlating diagnosis for the lisinopril. The nausea, vomiting, and edema are indicative of chronic renal failure not acute renal failure.

2. A resident physician continually documents "CHF" without further clarification in patients' medical records. What is the most likely rationale for this documentation practice?

No problem exists with this documentation as CHF without further clarification is acceptable. The resident is not qualified to make a more definitive determination of the type of CHF. The resident lacks knowledge regarding the need for further clarification. There is not enough clinical information to determine the type of CHF.