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Patient record analysis

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Your final project for this course will be a patient record analysis. You will apply the knowledge of anatomy, physiology, and pharmacology that you have developed during this course in a thorough review of existing patient information. Specifically, you will review a patient’s history and a discharge chart from a recent physician visit, explaining the reasons behind diagnosis

or (diagnoses) based on documented symptoms. You will also cite any inconsistencies or concerns and discuss potential and current treatments, all in preparation for your future coding practices. It may seem unnecessary to learn so much about pathophysiology and pharmacology for a career in health information management, but such knowledge is essential in ensuring the accuracy of patient records, coding, and billing.


The project is divided into two milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Three and Five. The final product will be submitted in Module Seven.


In this assignment, you will demonstrate your mastery of the following course outcomes:


·Analyze the pathophysiology of commonly diagnosed health conditions for anticipating the pharmacological needs of patients

·Differentiate between common health conditions that present similar symptoms using evidence – based resources for ensuring accurate patient health records

·Analyze standard pharmacological groupings and their specific drugs for their uses in treating patient symptoms and diseases

·Integrate foundational concepts of anatomy, physiology, and medical terminology into the analysis of symptoms, diagnosis, and treatment options for informing accurate coding practices




Your patient analysis should answer the following prompt Using the provided Final Project Patient File (attached), critically analyze the patient’s medical and family history and dissect the discharge chart from the patient’s recent visit. There are several inaccuracies and inconsistencies in this patient file; the pages of the file that contain issues are marked in the upper right – hand corner with red bookmarks. You must identify a total of three true issues with the patient file, explain what makes each identified issue a true issue, and discuss how you would approach addressing each issue in a real professional setting. Specifically, the following critical elements must be addressed:


I. Patient History Analysis


a) Summarize the patient history, explaining key patient demographics and family history that could be risk factors for common diseases.

b) Identify the past diagnosis (or diagnoses, if more than one exists in the file) and explain how the diagnosis was made. Specifically, what tests were done?

c) Discuss the symptoms the patient showed according to the file. Why and how did these symptoms lead the doctors to order certain tests?

d) What alternate diagnosis (or diagnoses) could these symptoms have indicated? Explain using evidence – based resources to support your conclusions.

e) Using supportive details from peer – reviewed resources, explain the pathophysiology of the diagnosis. In other words, how does the diagnosed disease develop and progress in the body?

f) Identify the past prescribed medications the patient is taking and explain the purposes of their larger

pharmacological groupings.

g) Explain what symptoms the specific medications are meant to treat, using resources to support your claims about the impact of the medication on the symptoms.

h) Illustrate how these medications impact the body and its functions. Use examples to support your explanations.


II. Recent Visit Analysis


a) Explain why the patient has returned to the doctor’s office. What symptoms and signs is the patient experiencing?

b) Analyze the new symptoms and signs to determine whether the past diagnosis is still a reasonable conclusion or could have been a

misdiagnosis. Use specific information from both the recent visit and the patient history to inform your analysis.

c) Based on the new signs, symptoms, and potential diagnosis (if the doctor has made a new diagnosis), discuss what new or potential

treatments would be appropriate. Why?


III. Identification of Record Inaccuracies


a) The patient file contains several inaccuracies and inconsistencies. Using your knowledge of medical terminology, anatomy, and physiology, articulate three issues you’ve identified.

b) Explain in detail what makes the identified issues a problem in terms of patient health and recordkeeping. Be sure to use appropriate medical terminology, references to anatomy, and concepts of normal physiology, where appropriate.

c) Discuss the impact of the issues on the patient, the coding system, and the billing system if they had not been caught, using the appropriate terminology.

d) Illustrate how you would work to address each issue, with specific detail regarding who you would pull into the discussion and who would be responsible for the particular details of each issue in a real medical setting.


In this Module, you will complete your record inaccuracies identification and submit your completed patient record analysis. It should be a complete, polished artifact containing all of the critical elements of the final product. It should reflect the incorporation of feedback gained throughout the course.


The length of your patient record analysis will depend on the issues you find in the file, but it will likely be 8–10 pages with an

additional page for references. All citations should be made according to the latest version of APA guidelines.

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