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Your final project should discuss the following critical elements. Make sure you review your final project before you submit it, and make sure it discusses all the critical elements and answers the questions.

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  1. Patient History Analysis
    1. a)  Did you summarize the patient history, explaining key patient demographics and family history that could be risk factors for

      common diseases?

    2. b)  Have you identified the past diagnosis (or diagnoses, if more than one exists in the file) and explained how the diagnosis was

      made? Specifically, what tests were done?

    3. c)  Did you discuss the symptoms the patient showed according to the file? Did you discuss why and how these symptoms led the

      doctors to order certain tests?

    4. d)  Did you include what alternate diagnosis (or diagnoses) these symptoms could have indicated? Did you use evidence-based

      resources to support your conclusions?

    5. e)  Using supportive details from peer-reviewed resources, did you explain the pathophysiology of the diagnosis? In other words,

      how does the diagnosed disease develop and progress in the body?

    6. f)  Have you identified the past prescribed medications the patient is taking and explained the purposes of their larger

      pharmacological groupings?

    7. g)  Did you explain what symptoms the specific medications are meant to treat, using resources to support your claims about the

      impact of the medication on the symptoms?

    8. h)  Did you illustrate how these medications impact the body and its functions? Did you include examples to support your

      explanations?

  2. Recent Visit Analysis
    1. a)  Did you explain why the patient has returned to the doctor’s office? Did you discuss what symptoms and signs the patient is

      experiencing?

    2. b)  Did you analyze the new symptoms and signs to determine whether the past diagnosis is still a reasonable conclusion or could

      have been a misdiagnosis? Did you use specific information from both the recent visit and the patient history to inform your analysis?

c) Based on the new signs, symptoms, and potential diagnosis (if the doctor has made a new diagnosis), did you discuss what new or potential treatments would be appropriate? Why?

III. Identification of Record Inaccuracies

  1. a)  The patient file contains several inaccuracies and inconsistencies. Using your knowledge of medical terminology, anatomy, and

    physiology, did you articulate three issues you have identified?

  2. b)  Did you explain in detail what makes the identified issues a problem in terms of patient health and record keeping? Did you use

    appropriate medical terminology, references to anatomy, and concepts of normal physiology, where appropriate?

  3. c)  Did you discuss the impact of the issues on the patient, the coding system, and the billing system if they had not been caught,

    using the appropriate terminology?

  4. d)  Did you illustrate how you would work to address each issue, with specific detail regarding who you would pull into the

    discussion and who would be responsible for the particular details of each issue in a real medical setting?

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Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

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