Pain Documentation Of Pain
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Your Medical Documentation Matters
www.cms.govThis is the case study used during the “Your Medical Documentation Matters” presentation. It is ... ambulance with acute onset of severe pain and inability to stand or bear weight on the leg. His vital signs . showed a temperature of 100.7 (T 100.7), blood pressure of 90 over 45 (BP 90/45), heart rate of 95 beats per ...
Wound Measurement & Documentation Guide final092112
www.hqi.solutionsPain Assessment: • Rate on scale of 1-10 before, during and after treatment; episodic or chronic • Interventions for pain Wound Progress: • Improving, deteriorating, no change • Interventions in place; pillows, low air loss beds, special devices, nutritional supplements, etc. • Continued treatment or notify MD and
Coding Common Respiratory Problems in ICD-10
www.aafp.orgCode R07.0, “Pain in throat,” specifically excludes “sore throat (acute),” but J02.9, ... Your documentation will need to support whichever clas-sification you use. 3. Inflammation vs ...
Documentation: Accurate and Legal - - RN.org®
www.rn.orgDocumentation is a form of communication that provides information about the healthcare client and confirms that care was provided. Accurate, objective, and ... determine a plan of care for a client with pain and diarrhea. NANDA Nursing diagnosis NIC Intervention NOC Expected outcomes Chronic pain Pain management Medication management ...
GUIDELINES: PHYSICAL THERAPY DOCUMENTATION OF …
www.apta.orgMay 19, 2014 · documentation guidelines in clinical areas, while at the same time providing guidance for the physical therapy profession across all practice settings. Documentation may also need to address additional regulatory or payer requirements. Finally, be aware that these guidelines are intended to address documentation of patient/client management, not