Problem:
- Discuss the specificity in the codes assigned around the diagnosis.
- Discuss how documentation relates directly to code assignment. Need Assignment Help?
Fred is a 68-year-old male that came to the doctor's office complaining of low body temperature, chills, low blood pressure and was very confused. His wife says he has been like this for several days. The nurse takes down the history and takes the blood pressure and temperature. Fred does not have a history of low blood pressure and is not taking any medicine at this time. The blood pressure is 98/50 and has a temp of 95.4. The doctor comes in and starts to examine Fred. Upon examination, the doctor notices a rather large cut on Freds' right leg. Fred works in construction. Fred has no clue where he got the cut from. This cut is red and has a white puss oozing out of it. The doctor cleans out the wound and but some antibiotic ointment on it. It is obvious to the doctor that the cut is infected. The doctor decides to draw some blood to rule anything else out. The nurse comes and draws the blood and sends it off to the lab. Fred was sent.