NURS601B APRN Bridge course Week 7 Assignment Comprehensive H&P Case Study

NURS601B APRN Bridge course
Week 7 Assignment
Comprehensive H&P Case Study
The purpose of this paper is to understand the importance of accurate medical record documentation to record pertinent facts, findings, and observations about a patient’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.
Step 1:
Review and critique the comprehensive H&P and thoroughly answer the questions that follow in complete sentences and paragraphs using question and answer APA format.
Step 2:
Use current APA format to style your paper and to cite your sources. Your source(s) should be integrated into the paragraphs. Use internal citations pointing to evidence in the literature and supporting your ideas. Include a title page and a reference page listing the sources you used.
Step 3:
Keep in mind the requirements set forth in the 1997 Guidelines of Documentation for Evaluation and Management by CMS. Visit, and then search “1997 Guidelines of Documentation for Evaluation and Management” for information that should be included in a medical record.
Answer the following questions:
1. Does this document meet the CMS guidelines for documentation of a comprehensive history and physical? Why or why not? Be specific.
2. Critically analyze the H&P and list any errors. Identify the strengths of the H&P.
3. Did any questions come to mind that you are unable to answer after reading the H&P?
4. Are the conditions listed in the assessment section reasonably supported by the history? Why or why not? Explain your rationale.
5. Did you identify other differential diagnoses or conditions that should be included in the assessment? If so, list them.
6. List the ICD-10 code for each of the following (go to and search for the ICD-10 Codes):
Moderate persistent asthma with (acute) exacerbation: ______________
Pneumonia, unspecified organism: ______________
Essential (primary) hypertension: ______________
Hyperlipidemia, unspecified ______________
Obesity: ______________
7. Is it appropriate to include the ICD-10 code for pneumonia when billing for this visit? Why or why not?
8. Is the plan reasonable based on the assessments listed? Why or why not?
9. List 3 patient education strategies relevant to the case study including specific medication teaching. Include references.
10. List health promotion recommendations from AHRQ according to age/gender/conditions. Cite your references.
Your paper should be 2-3 pages not including the title and reference pages. A minimum of 2 sources, not including your texts, must be incorporated into your paper.
Use current APA format to style your paper and to cite your sources. Your source(s) should be integrated into the paragraphs. Use internal citations pointing to evidence in the literature and supporting your ideas. Include a title page and a reference page listing the sources you used.
601B Comprehensive H&P guidelines.docx
A comprehensive H&P for patient Anne Smith is shown. Ms. Smith is a new patient presenting to an internal medicine office-based practice. Carly Sanders, an experienced nurse practitioner, authored the H&P.
Patient Name: Anne Smith Age: 55
Date of Visit: 2-14-2016 Gender: Female
Information Source: Patient, reliable source, face-to-face office visit
Chief Complaint: Follow up after Emergency Department visit
History of Present Illness: Reports were seen in the Emergency Department approximately 2 weeks ago and was treated for bronchitis with an unknown antibiotic that she has now finished. Was prescribed a refill of an Albuterol MDI as well. Pt continues to report cough and shortness of breath with exertion. Cough and shortness of breath have not improved since last Emergency Room visit. Cough reported as dry and present day and night without provocation. Has been using Albuterol MDI 4–5 times per day with slight relief of shortness of breath symptoms. Pt reports multiple diagnoses of bronchitis last year and has been using Albuterol MDI multiple times daily for the past 6 months or more.
PMH: Hypertension. Bronchitis. Hyperlipidemia. Obesity.
Medications: HTCZ 25mg BID. Albuterol MDI q4h PRN. Simvastatin 20mg daily. OTC Aleve 1–2 tabs PRN headaches.
Allergies: Codeine. Shellfish.
Family History: Mother and Father with CV disease. Son with asthma. Daughter with hypertension. Denies family history of DM. Mother diagnosed with breast cancer at age 40, died at 44.
Social History: Retired from clerical work. Widowed. Lives with adult children and assists with watching grandchildren. Denies tobacco use, ETOH use, drug use.
Review of Systems:
GENERAL: Reports good sleep but decreased energy levels. Denies fever.
CV: (-) palpitations. (-) CP. (-) swelling.
PULM: (+) SOB with exertion. (+) wheezing. (+) dry cough. (-) hemoptysis.
ENT: (-) rhinorrhea. (-) sinus pain/pressure. (-) ear pain/pressure. (-) sore throat.
CV: RRR, no murmur.
Pulm : Posterior inspiratory wheezes bilaterally in all lobes. No rales/rhonchi/crackles. No consolidation present with percussion. Equal rise and fall of chest. No accessory muscle use.
Ears: Bilat TM pearly white, canals clear, no discharge, no external ear tenderness.
Nose: Nasal mucosa pink, moist. No discharge present. No sinus pressure pain.
Throat/Neck: Oral mucosa pink/moist. Tonsils grade 1 without exudate. No lymphadenopathy.
General: Obese caucasian female. Affect appropriate. Appears very anxious. Appropriately dressed. No obvious deformity.
VS: Temp 97.8, Pulse 72 RR 22, BP 140/90, BMI 32
1. Moderate persistent asthma with (acute) exacerbation
2. Pneumonia, unspecified organism
3. Essential (primary) hypertension
4. Hyperlipidemia, unspecified
5. Obesity
Dx Plan: None
Tx Plan: Rx: Qvar 40mcg/spray 2 puffs BID. Rx: Albuterol MDI 1-2puffs q4h PRN wheezing. Rx: Inhalation Spacer Device. Refill HTCZ 25mg PO BID #30 with 2 refills.
Refill Simvastatin 20mg PO QD #30 with 2 refills.

Struggling to find relevant content or pressed for time? – Don’t worry, we have a team of professionals to help you on
NURS601B APRN Bridge course Week 7 Assignment Comprehensive H&P Case Study
Get a 15% Discount on this Paper
Order Now
Calculate the price
Make an order in advance and get the best price
Pages (550 words)
*Price with a welcome 15% discount applied.
Pro tip: If you want to save more money and pay the lowest price, you need to set a more extended deadline.
We know how difficult it is to be a student these days. That's why our prices are one of the most affordable on the market, and there are no hidden fees.

Instead, we offer bonuses, discounts, and free services to make your experience outstanding.
Sign up, place your order, and leave the rest to our professional paper writers in less than 2 minutes.
step 1
Upload assignment instructions
Fill out the order form and provide paper details. You can even attach screenshots or add additional instructions later. If something is not clear or missing, the writer will contact you for clarification.
Get personalized services with MyCoursebay
One writer for all your papers
You can select one writer for all your papers. This option enhances the consistency in the quality of your assignments. Select your preferred writer from the list of writers who have handledf your previous assignments
Same paper from different writers
Are you ordering the same assignment for a friend? You can get the same paper from different writers. The goal is to produce 100% unique and original papers
Copy of sources used
Our homework writers will provide you with copies of sources used on your request. Just add the option when plaing your order
What our partners say about us
We appreciate every review and are always looking for ways to grow. See what other students think about our do my paper service.
Human Resources Management (HRM)
Thanks for your assistance and promptness.
Customer 452701, November 1st, 2022
All points covered perfectly! Great price!
Customer 452707, March 12th, 2023
Customer 452813, June 25th, 2022
Customer 452813, June 29th, 2023
Customer 452813, July 3rd, 2022
Completed early! Awesome job!!!!!
Customer 452453, March 8th, 2023
Human Resources Management (HRM)
The paper was good but they writing the paper labeling me as a Registered Nurse and I have express this several time so o had to go in make corrections
Customer 452901, April 8th, 2024
Business and administrative studies
Perfect as always!
Customer 452909, April 15th, 2023
excellent job i will be coming back for any future papers if I have too.
Customer 452611, October 11th, 2021
Thank you so much for your help so I do not go insane from trying to do this. I have 2 more courses to do. Probably will be using you again.
Customer 452675, November 28th, 2021
Thanks for the help, appreciate it
Customer 452821, August 27th, 2022
I requested two pages and only have one page and the second pages is references.
Customer 452475, August 22nd, 2022
15% OFF your first order
Use a coupon FIRST15 and enjoy expert help with any task at the most affordable price.
Claim my 15% OFF Order in Chat

Good News ! We now help with PROCTORED EXAM. Chat with a support agent for more information


Thank you for choosing MyCoursebay. Your presence is a motivation to us. All papers are written from scratch. Plagiarism is not tolerated. Order now for a 15% discount

Order Now