Inpatient sample charts / Sample Inpatient cases / Inpatient DRG coding / DRG coding sample charts
H&P
Procedure Information:
Pre-Op Diagnosis Codes:
* OSTEOARTHRITIS OF
RIGHT HIP
Procedure(s) with comments:
HIP REPLACEMENT ANTERIOR APPROACH TOTAL - HANA table
Big C-arm #2 on opposite side of table
Total hip 1, anterior hip set, Depuy add ons
Gripper x 1, Drain bag
Depuy Pinnacle cup, Actis stem, Corail for back-up
Requested Anesthetic type:
Spinal
I contacted patient and confirmed that I was speaking to the
correct person.
Patient expressed understanding and agreed to proceed with
the video visit and treatment if necessary. Consent documented in visit
navigator. Connection was successful.
Chief Complaint and History of Present Illness:
XXX is a 72 Y female with a history of R hip OA for which
she is scheduled for surgery.
Patient Active Problem List
OSTEOARTHRITIS OF
RIGHT HIP
Added
automatically from request for surgery
1225017
HYPERLIPIDEMIA
ANOSMIA
SENILE PURPURA
ESOPHAGEAL SPASM
HX OF ABNL PAP SMEAR
HX of CIS diagnosed
and treated in 1984
HX OF COLONOSCOPY
Mod to
severe diverticula, repeat screening 6-2023
DIVERTICULOSIS OF
COLON
HX OF SKIN CANCER
LUMBOSACRAL
RADICULOPATHY
ACTINIC KERATOSIS
HTN (HYPERTENSION)
ASTHMA
Resolved Hospital Problems
No resolved problems to display.
Past Surgical History:
Procedure Laterality Date
• CONE
BIOPSY OF CERVIX
for
CIS 1984
Allergies
Allergen Reactions
• Co-Trimoxazole
rash
• Codeine
swelling
• Hydrocodone-Acetaminophen
upset stomach.; tylenol is ok
• Nsaids,
Non-Selective [Non-Steroidal Anti-Inflammatory Agents] Renal Toxicity
Cr increased to 1.78 after
several days of PO Toradol.
• Prochlorperazine
hospitalization
Tobacco Use
• Smoking
status: Never Smoker
• Smokeless
tobacco: Never Used
Vaping Use
• Vaping
Use: Never used
Substance Use Topics
• Alcohol
use: No
Alcohol/week: 0.0 standard drinks
• Drug use: No
E-Cigarettes/Vaping
Questions Responses
E-Cigarette/Vaping
Use Never User
Social History
Substance and Sexual Activity
Drug Use No
Family History: non-contributory
Family History of Anesthesia Complications: Unknown
Personal History of Anesthesia Complications: none
Review of Systems:
General: Denies fever, chills, weight change, fatigue and
weakness
Cardiovascular: Denies chest pain, orthopnea and
palpitations with exercise or at rest
Respiratory: Denies recent SOB and cough (productive)
Neuro: Denies fainting, seizures and headaches Falls: no,
Delirium: no, Assistive devices: uses a cane sometimes
GI: Denies GERD
GU: Denies dysuria, frequency and urgency
Heme: Denies bleeding but has easy bruising
Musculoskeletal: Denies joint pain and decreased ROM neck
Skin: Denies rashes and skin changes over the surgical site
Other: none
Has the patient had a positive COVID test in the last 7
weeks? no
Has the patient had a COVID test ordered ? yes
Physical Exam:
General appearance: alert, well appearing, and in no
distress
Neck: normal range of motion
Respiratory: no respiratory distress
Mental status: alert, oriented to person, place, and time,
normal mood, behavior, speech, dress, motor activity, and thought processes
Most recent information from chart review:
Estimated body mass index is 25.06 kg/m² as calculated from
the following:
Height as of
3/31/22: 1.626 m (5' 4").
Weight as of
3/31/22: 66.2 kg (146 lb).
SpO2 Readings from Last 3 Encounters:
03/31/22 98%
10/11/18 98%
02/27/18 95%
BP Readings from Last 3 Encounters:
03/31/22 138/72
07/06/21 135/75
06/17/21 140/76
Pulse Readings from Last 3 Encounters:
03/31/22 106
07/06/21 95
06/17/21 98
Temp Readings from Last 3 Encounters:
03/31/22 99
°F (37.2 °C) (Temporal)
07/06/21 98.3
°F (36.8 °C) (Temporal)
01/28/20 99.5
°F (37.5 °C) (Tympanic)
Pre-Operative Screening
Pregnancy Testing:
N/A (male, nonmenstruating female, hx of hysterectomy)
Obstructive Sleep Apnea Criteria:
None
Exercise/Functional Capacity:
4-6 mets: e.g. Yard work, climb a flight of stairs, walk up
a hill and Patient's current level of activity includes the following: Up until
recently was able to walk to the gym and exercise a bit 2-3 times per
week. Limited by hip pain, no SOB
History of Cardiac Stent: No
Objections To Blood Transfusions: NO
Review of Other Relevant Data:
EKG: date 2018, result
Baseline artifact is present
Sinus tachycardia
RSR' in V1 or V2, probably normal variant
Right axis deviation
Nonspecific ST-T wave changes.
Compared with previous tracing no significant
change.
Echo: none
No results found for this or any previous visit (from the
past 4320 hour(s)).
Cardiac Stress Test: none
Patient Class: Hospital Ambulatory Surgery
Pneumonia Prevention Education: N/A, hospital ambulatory
surgery
Life Care Planning:
Medical Decision Maker? Patient provided information
today--Tim Molinare (listed as emergency contact)
Advanced Directive? no
Assessment and Plan:
XXX is a 72 Y female is optimized for planned surgery.
Preliminary ASA Class: 2
The following studies have been ordered or are pending at
the time of this visit: EKG to be done in pre-op
Patient Active Hospital Problem List:
OSTEOARTHRITIS OF
RIGHT HIP
Assessment: Noted
Plan:
- Operative plan per orthopedist
- No further pre-op testing indicated, but will get ECG in
pre-op for new baseline.
- Recommend post-op DVT prophylaxis with ASA 81 mg BID for 4
weeks.
- Med holds as below
HTN (HYPERTENSION)
Assessment: Noted
Plan:
- Hold HCTZ and losartan on DOS
ESOPHAGEAL SPASM
Assessment:
Diet-controlled, has not used NTG in years
Plan:
- OUtpatient fup
HYPERLIPIDEMIA
Assessment: Never
started statin.
Plan:
-F/up with PCP
Patient Instructions:
The patient was provided the following PREOPERATIVE
instructions:
PRIOR TO SURGERY
Stop all non-prescription vitamins, herbs, and supplements 1
week before surgery.
Continue all of your regularly scheduled medications
DAY OF SURGERY
Do not take your blood pressure medications
(Hydrochlorothize and losartan) on the morning of surgery.
