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

Want create site? With you can do it easy.

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.

Did you find apk for android? You can find new and apps.

Instant Nursing Papers
Hire a Nursing Expert
Pages (550 words)
Approximate price: -

Why Choose Instant Nursing Papers?

Quality Nursing Papers

We assist students in achieving the best top-grade in their nursing papers, and in compliance with the provided instructions. Have your nursing paper written with a certified specialist Ph.D., Bachelor's, and Master's graduates with many years of experience in academic writing.

Experts with Ph.d., MDs and DNP Holders

Our writers have acquired Ph.D., MDs and DNP credentials from world class institutions. Our writers can handle papers from any discipline and can handle over 100+ subjects.

Nursing Papers Cheap

We provide a great deal of student-friendly prices and professionalism with all our nursing essay writing services. Our paper writing services have a user-friendly interface and professional nursing academic assistance. We are committed to assisting all students with their nursing assignments and projects regardless of their academic level.

Fast Paper Delivery

Our writers follow a strict schedule to ensure papers are delivered before the deadline to enable our editors to proofread before the final delivery to our customers. We strictly observe the early delivery of assignments to meet our clients' deadlines.

Plagiarism-free Nursing Papers

Our expert nursing paper writers are dedicated to conducting thorough research and writing papers from scratch to deliver original papers. To avoid paper plagiarism, all orders go through steps of writing, editing, and proofreading.

24Hour Customer Help

Our customer support is available 24/7/365 to help clients and make their paper writing services easy to use. Our experienced support team is available to answer your queries any time, 24 hours a day.

Try it now!

Calculate the price of your order

We'll send you the first draft for approval by at
Total price:

How it works?

Follow these simple steps to get your paper done

Place your order

Fill in the order form and provide all details of your assignment.

Proceed with the payment

Choose the payment system that suits you most.

Receive the final file

Once your paper is ready, we will email it to you.

Our Nursing Papers Writing Service

We provide Nursing Assignment Services to Nursing students. Also, we are not limited to providing Nursing assignment help to students only. We also provide assignment help and solutions to community health nursing, Anatomy & Physiology, Microbiology, Biochemistry and Biophysics, and Nutrition & Dietetics.


Nursing Essays

Sit back, relax while our writers sort you out on your most daunting nursing essay queries on how to write a good nursing essay. We got you if you are looking for the best nursing essay services.


Nursing Projects

It is no doubt that qualifying for a nursing career is difficult and requires a series of tests. Most nursing students must put in a lot of work in their assignments and coursework. will help you answer queries such as “who can write my nursing research paper?”.


Nursing Dissertation Help will save you the hustle of undergoing pressure or even depression while doing your nursing dissertation paper. Save yourself from all the long sleepless nights and pressure by working with our best nursing dissertation writing professionals.


Nursing Coursework Help

If you happen to hop into our site in search of nursing coursework help, look no further. We are the number one solution for the best nursing coursework assignments. Therefore, to complete the best APA nursing coursework, seek help from professional nursing coursework experts at