HIMA 110: Week 5 Medical Record Review Worksheet
Description
This week's assignment is to complete the attached worksheet and apply your learning by exploring a sample medical record for a
patient who underwent an operative procedure. Two sample records are attached below, along with the worksheet. Enjoy this
practical application of our learning!
Reminders
Submit your response using the attached worksheet.
Should you have any questions, contact me before the due date.
Submit your completed worksheet as an attachment to the Week 5 Assignment.
Record Location Question Response
History and What was the chief complaint? Exertional chest pain and shortness of breath
Physical
List briefly the details of the present 6 month history of worsening exertional chest pain and short ness of
illness. breath. Chest pain described as squeezing sensation in the substernal
area and radiating to the left arm. Pain triggered by physical activity.
Shortness of breath on exertion. Fatigue during physical activities.
List briefly relevant social and family History of smoking for 30 years and quit smoking 5 years ago. No
history. alcohol or drug use. No family history of coronary artery disease or
other cardiac conditions.
What is included in the review of Cardiovascular, Respiratory, Gastrointestinal, Genitourinary,
systems? (Remember, this will be in Musculoskeletal, Neurological, Hematologic, Endocrine,
the history, not the physical.) Allergic/Immunologic.
, 2
What were the patient’s vital signs? Blood Pressure: 132/78 mmHG. Heart Rate: 72 beats per minute.
Respiratory Rate: 16 breaths per minute. Temperature: 98.6 degrees
Fahrenheit.
What abnormal findings are included No abnormal findings
in the physical?
What is the provisional diagnosis? Coronary Artery Disease
What is the plan? Patient is scheduled to undergo CABG to improve blood flow to the
affected coronary arteries. She will be admitted to the hospital the
day before surgery for preop prep and eval, including lab tests,
electrocardiogram, and cardiac imaging. Postop she will be closely
monitored by CICU and transferred to cardiac step-down unit. Cardiac
rehab and medications will be prescribed for her recovery and long
term management.
Operative What is the preoperative diagnosis? If Coronary Artery Disease. It is listed in the H&P provisional diagnosis.
Report/Patholog it was not listed on the operative
y report, where is it located in the
record?
What is the postoperative diagnosis? Coronary Artery Disease
Who was the surgeon? Jim Shorts MD
What operation was done? Coronary Artery Bypass Grafting (CABG)
Description
This week's assignment is to complete the attached worksheet and apply your learning by exploring a sample medical record for a
patient who underwent an operative procedure. Two sample records are attached below, along with the worksheet. Enjoy this
practical application of our learning!
Reminders
Submit your response using the attached worksheet.
Should you have any questions, contact me before the due date.
Submit your completed worksheet as an attachment to the Week 5 Assignment.
Record Location Question Response
History and What was the chief complaint? Exertional chest pain and shortness of breath
Physical
List briefly the details of the present 6 month history of worsening exertional chest pain and short ness of
illness. breath. Chest pain described as squeezing sensation in the substernal
area and radiating to the left arm. Pain triggered by physical activity.
Shortness of breath on exertion. Fatigue during physical activities.
List briefly relevant social and family History of smoking for 30 years and quit smoking 5 years ago. No
history. alcohol or drug use. No family history of coronary artery disease or
other cardiac conditions.
What is included in the review of Cardiovascular, Respiratory, Gastrointestinal, Genitourinary,
systems? (Remember, this will be in Musculoskeletal, Neurological, Hematologic, Endocrine,
the history, not the physical.) Allergic/Immunologic.
, 2
What were the patient’s vital signs? Blood Pressure: 132/78 mmHG. Heart Rate: 72 beats per minute.
Respiratory Rate: 16 breaths per minute. Temperature: 98.6 degrees
Fahrenheit.
What abnormal findings are included No abnormal findings
in the physical?
What is the provisional diagnosis? Coronary Artery Disease
What is the plan? Patient is scheduled to undergo CABG to improve blood flow to the
affected coronary arteries. She will be admitted to the hospital the
day before surgery for preop prep and eval, including lab tests,
electrocardiogram, and cardiac imaging. Postop she will be closely
monitored by CICU and transferred to cardiac step-down unit. Cardiac
rehab and medications will be prescribed for her recovery and long
term management.
Operative What is the preoperative diagnosis? If Coronary Artery Disease. It is listed in the H&P provisional diagnosis.
Report/Patholog it was not listed on the operative
y report, where is it located in the
record?
What is the postoperative diagnosis? Coronary Artery Disease
Who was the surgeon? Jim Shorts MD
What operation was done? Coronary Artery Bypass Grafting (CABG)
