Sally Smith is reviewing an inpatient record for coding. She notes that the face sheet, diagnostic testing reports, and discharge summary contain different diagnoses. What should she do to code the diagnoses?
a. Use the diagnoses on the face sheet.
b. Select all the diagnoses on all three forms of documentation.
c. Use the diagnoses on the discharge summary.
d. Query the provider for clarification.
d
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You are transporting a patient who experienced a right-sided head injury after a large refrigerator fell and pinned his head between the appliance and the floor. On scene, the patient was responsive to verbal stimuli with the following vital signs: pulse, 96 beats/min; respirations, 16 breaths/min; blood pressure, 134/66 mmHg; and SpO2, 95%. During transport, as you reassess the patient, what would be the clearest sign that the head injury is worsening?
A) Increasing edema to the right side of the head B) Blood pressure of 108/68 mmHg C) Responding only to painful stimuli D) Heart rate of 112 beats/min