Health Data Content Question & Answer Guide (With Explanation)

Understanding this question requires applying core subject principles.

What This Question Is About

This question relates to health data content and requires a structured academic response.

How to Approach This Question

Break the problem into smaller parts and analyze each logically.

Key Explanation

This topic involves health data content. A strong answer should include explanation, application, and examples.

Original Question

HEALTH DATA CONTENT This record is the basis for the questions that follow: Northgate Family Practice Leo Bruschetta, MD 82015 Sunshine Lane Kayla Long, MD Allwaysbright, NC 10501 Samuel Bruce, MD PATIENT VISIT NOTE Patient: Caroline M. Myers MRN: 10185 DOB: 08-15-1950 DATE OF VISIT: 10/11/2013 HPI: Mrs. Myers is a 63-year-old female who was at the mall when she slipped on the wet floor in Belk’s Department Store two days ago. She has been experiencing severe pain in her right knee, which has worsened over the past 12 to 24 hours. She states that the pain is more of a dull ache. She has not taken any other medications other than Aleve, which she normally takes anyway. PMH: Mrs. Myers has been in relatively good health. She has type II diabetes mellitus and some osteoarthritis of the ankles bilaterally, other than that, no chronic medical problems. She has had her flu shot this year, and had Prevnar 13 on her last visit in January. She has been given a prescription for the shingles vaccine; however, she has not done that yet. CURRENT MEDICATIONS: Metformin 1000 mg q.d., OTC Aleve, and Cozaar, 50 mg q.d. She also takes a multivitamin and a fish oil supplement. PHYSICAL EXAM: Vital signs: Temp: 99.2 degrees F; heart rate 68; respirations 18; Pulse ox: 98%. Weight: 180; height 64 inches. Heart: Regular rate and rhythm. Pulmonary: Respirations 18 and unlabored. Extremities: The right knee is swollen and tender. ROM is WNL. The left knee is without swelling or tenderness; ROM is WNL. The upper extremities are without swelling or tenderness. ASSESSMENT: Knee sprain. PLAN: X-ray of right knee. Suspect sprain, but will refer to orthopedic surgeon if indicated. Meanwhile, keep right leg elevated; apply heat and ice at 20 minute intervals for the next 24 to 48 hours. Continue Aleve as currently being taken. __ Kayla C. Long, MD___________________________12/15/2013_____ Signature of provider Date Dictated: 11/25/2013 Transcribed: 11/26/2013 Questions are found on the next page; you are to answer them in a different colored font and upload to Bb. You may need to use other resources to answer the questions. The documentation above is part of the medical record of patient Caroline M. Myers in the offices of Northgate Family Practice. Based on this record, answer the following questions completely: 1. What is the patient’s chief complaint? 2. For what condition is the patient taking Metformin? 3. Of the information in the record, which is subjective (list all that is subjective)? 4. Of the information in the record, which is objective (list all that is objective)? 5. For what condition is the patient taking Prevnar 13â„¢? 6. What is Dr. Long’s assessment of the patient’s problem(s)? 7. Based on what you see in front of you, in which medium is this record being maintained (paper, EHR, web-based)? 8. Is this a primary or secondary source of data? 9. What is the meaning of the following abbreviations? a. HPI b. DOB c. MRN d. PMH e. OTC f. q.d. g. WNL h. ROM 10. Analyze the content of this record. Is there anything that you see which is not in keeping with standard record keeping practices, such as timeliness, completeness, accuracy, and appropriateness of the data found in this record?

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