Scenario D (Questions 18-20): \"A 75-year-old gentleman was admitted for control

Question

Scenario D (Questions 18-20): "A 75-year-old gentleman was admitted for control of his atrial fibrillation. Two days after admission the attending physician documented the presence of a decubitus ulcer on the buttocks. After thorough review of the health record, the nursing intake documentation did identify the presence of the decubitus ulcer and stated it was stage II. Final diagnosis: Atrial fibrillation with decubitus ulcer on buttocks." 18. What were the documented final diagnoses? Check all that apply: ?Stage II ?Atrial fibrillation ?Decubitus ulcer buttocks ?Nausea 19. What information is documented about one of the diagnoses and is needed for accurate coding? Check all that apply: ?Location ?Size ?Stage ?Treatment 20. Can the inpatient coder assign a code based on the nurse’s documentation? ?Yes ?No

Explanation / Answer

18. atrial fibrillation, decubitus ulcerbuttocks (stage 2 has been stated but it is not mentioned in the final diagnosis)

19. location, stage (no details have been mentioned regarding the size and treatment of the ulcer. Location of the ulcer and stage of the ulcer is mentioned)

20. yes

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