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Read the attached History & Physical report on Elena Montero. If you were transc

by | Jun 22, 2022 | Medicine and Health | 0 comments

 

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Read the attached History & Physical report on Elena Montero.
If you were transcribing this report, how would the appropriate and accurate use of obstetrical terminology support the following in performing their jobs:
ICD-10-CM/PCS coders
Nurses
Physicians
If Elena’s obstetrical history had been that of a gravida 7, para 5, AB 2 female how would that be understood by all of the above?
Why is it important to record the fetal heart tones, and what diagnostic tool is used to detect them?
Which factors, as noted in the obstetrical assessment form, might have given Elena a history of high-risk complications?
Was an episiotomy performed? If so, what type? What degrees of episiotomies are possible, and what do they signify?
What were the baby’s Apgar scores? What does an Apgar score represent?
What were Elena’s discharge instructions?

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