A surgical nurse is responsible for monitoring and ensuring quality healthcare for a patient following surgery. Assessment‚ diagnosis‚ planning‚ intervention‚ and outcome evaluation are inherent in the post operative nurse’s role with the aim of a successful recovery for the patient. The appropriate provision of care is integral for prevention of complications that can arise from the anaesthesia or the surgical procedure. Whilst complications are common at least half of all complications are preventable
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The article‚ “Pre-operative assessments of elective surgical patients‚” aims at emphasizing the importance of pre-operative assessments along with the rationale for their use in addition to ensuring the patient is medically fit prior to entering the operating room. In addition‚ well performed assessments prior to surgery also improve patient outcomes post-surgery. The article also states that the essential components of the pre-operative assessment should include: identifying current health concerns
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abbreviations. 6. The E/M code would be 99253. 7. Chief complaint (CC)‚ history or present illness (HPI)‚ review of systems (ROS)‚ past present family and/or social history (PFSH) 8. 1. # of diagnoses or management options (minimal‚ limited‚ multiple‚ or extensive) 2. Amount or complexity of data to review (minimal‚ none‚ limited‚ moderate‚ or extensive) 3. Risk of complication or death if the condition goes untreated (minimal‚ low‚ moderate‚ or high). 9. CPT code would be 99214. 10. The three
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What are the major differences between inpatient and outpatient hospital services? Describe how these differences affect the coding process and provide examples. There are some differences between the outpatient and inpatient services offered by the hospitals. The inpatient services deal with services provided in the form of overnight care provided to the patients. These services can be under different care units depending upon the needs of the patients. Example of some of these care units can
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"Surgery". This is the seven letter word that fascinates me and grasps my attention with no effort. As I sat in the hospital room with my sick young cousin‚ this was the only word I heard come out of the neurologist’s mouth. My interest in becoming a surgeon began at the young age of seven years old. I was‚ and still am‚ amazed at how profound such an act can be. As a seven year old‚ I was always the clean and well organized girl who was always inside cutting open her stuffed animals and sewing them
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OPERATIVE REPORT Patient Name: Putul Barua Patient ID: 135799 DOB: N/A Age: 42 Sex: M Room No: CCU4 Date of Admission: 01/07 Date of Procedure: 01/08 Admitting Physician: Simon Williams‚ M.D. (Pulmonology) Surgeon: Simon Williams‚ M.D. (Pulmonology) Assistant: N/A Preoperative Diagnosis: Recent-onset hemoptysis‚ history of tuberculosis. Postoperative Diagnosis: No tuberculosis lesions seen. Operative Procedure: Bronchoscopy Specimen Removed: Blood clots. IV Fluids: N/A Estimated
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Scenario: You are working in a community outpatient clinic where you perform the intake assessment on R.M.‚ a 38- year-old woman who is attending graduate school and is very sedentary. She reports overwhelming fatigue that is not relieved by rest. She states that she is so exhausted that she has difficulty walking to class and trouble concentrating when studying. Her face looks puffy‚ and her skin is dry and pale. She also reports generalized body aches and pains with frequent muscle cramps and
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Whilst the patient is in PACU‚ identify and discuss airway management (and rationales) as related to the case study (400 words) The post-operative patient is at risk for respiratory problems due to ineffective airway clearance related to changes in pulmonary physiology and function caused by anaesthetics‚ narcotics‚ mechanical ventilation‚ hypothermia and surgery. With increased tracheobronchial secretions secondary to the effects of anaesthesia‚ combined with ineffective coughing‚ and decreased
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CHAPTER 5 Content of the Patient Record: Inpatient‚ Outpatient‚ and Physician Office Chapter Outline Key Terms Objectives Introduction General Documentation Issues Hospital Inpatient Record—Administrative Data Hospital Inpatient Record—Clinical Data Hospital Outpatient Record Physician Office Record Forms Control and Design Internet Links Summary Study Checklist Chapter Review Key Terms addressograph machine admission note admission/discharge record admitting diagnosis advance directive
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has a different job in which it oversees throughout the organization. Their central offices are predominantly in Washington D.C.‚ although they do have some in Colorado‚ Texas‚ and Maryland. This does not include the many VA Medical Centers‚ Outpatient Clinics‚ Vet Centers‚ and Benefit Offices scattered throughout every state. This works well for the VA because with this structure not one department is covering all of the workload. Also‚ this structure spreads everything around so that each person
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