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(SOLVED)Tina Jones GI Documentation

(SOLVED)Tina Jones GI Documentation

Tina Jones GI Documentation

Tina Jones, a 28-year-old girl, appears with stomach concerns. The patient occasionally complained of stomach discomfort, bloating, constipation, and diarrhea. The patient felt full immediately after eating and experience acid reflux symptoms, including heartburn and regurgitation. Tina Jones GI Documentation

The patient’s vital signs were normal throughout the assessment. The abdomen was soft, not sensitive, and not swollen. There were no signs of masses or organomegaly. Bowel noises may be heard in all four quadrants. Irritable bowel syndrome (IBS), sadness, and anxiety are part of the patient’s medical history.

After analyzing the patient’s medical history, it was discovered that the patient had been diagnosed with IBS and had symptoms for many years. For depression and anxiety, the patient is now taking escitalopram and trazodone. The patient denies any drug allergies.

After a comprehensive evaluation, the healthcare practitioner suggested that the patient make certain lifestyle modifications to relieve her problems. The clinician suggested that the patient boost her fiber intake and eat more fruits and vegetables. The doctor also advised the patient to avoid spicy, fatty, and fried meals and carbonated beverages, caffeine, and alcohol. Tina Jones GI Documentation

In addition, the practitioner recommended a prescription to alleviate the patient’s acid reflux problems. Omeprazole is a proton-pump inhibitor that reduces the acid generated in the stomach. For optimal efficacy, the drug should be given 30 minutes before a meal, according to the supplier.

The patient was also advised to maintain a food diary to identify any trigger foods that may increase her symptoms. The doctor encouraged the patient to keep a journal of everything she eats and drinks and any symptoms she has after eating. The doctor also advised the patient to maintain a record of her bowel motions and note any changes in frequency or consistency.

The physician urged the patient to return in two weeks to check her progress and make any necessary adjustments to her treatment plan. The woman was also advised to seek medical assistance immediately if she had severe stomach discomfort, bloody stools, or trouble breathing.

The contact was recorded in the patient’s electronic health record (EHR), which included the patient’s medical history, physical exam results, and treatment plan. The clinician also recorded the patient’s vital signs, medication history, and allergies or bad drug responses.

To record the interaction, the physician utilized standardized medical language and coding, such as ICD-10 numbers for the patient’s diagnosis and CPT codes for any operations done. The clinician also documented the patient’s symptoms, exam results, and treatment plan using narrative descriptions.

The recording in the EHR by the physician enables continuity of care and ensures that other healthcare practitioners participating in the patient’s care have access to critical information. The EHR also makes it simple to follow the patient’s progress, any changes in her symptoms, and any modifications to her treatment plan.

Finally, Tina Jones appears with gastrointestinal symptoms such as stomach discomfort, bloating, constipation, and acid reflux. The healthcare practitioner suggested the patient make lifestyle modifications, take medication, and maintain a diet diary to detect any trigger foods. The clinician logs the interaction in the patient’s EHR, enabling continuity of treatment and simple monitoring of the patient’s progress. Tina Jones GI Documentation
Tina Jones GI Documentation

Tina Jones GI Documentation
Tina Jones – Gastrointestinal

Documentation / Electronic Health Record

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