Patient symptoms and physician diagnosis

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Reference no: EM133477980

You are currently an HIM Consultant for a large hospital system. You have been asked by the Hospital Administrator to present during one of the monthly lunch-and-learn sessions for physicians and their staff who would like to attend.

Your presentation will include information that will utilize examples from the following category list: Clinical Terminologies, (examples: RxNorm, LOINC, DSM-IV,) Classifications, (examples: ICD-11, ICD-10-CM, ICD-10-PCS, CPT-4 and HCPCS Level II), and Nomenclatures (example: SNOMED). This is not an exhaustive list, and you may select other examples to discuss.

Research the various terminologies, classifications, and nomenclatures listed above and their application, as well as other coding nomenclatures utilized by specialty physicians, such as dental, ophthalmology, etc. Reference scholarly library resources to research the above.

Create two hypothetical medical scenarios for an inpatient visit and an ambulatory visit of your choice. You will analyze four to 5-classification systems, coding nomenclatures and/or clinical terminologies, for each scenario.

You will:

1. Design and create the scenario, including patient symptoms and physician diagnosis(es).

2. Identify the setting, inpatient and ambulatory (specifically identify the ambulatory setting, e.g., ER, urgent care, clinic, physician visit, etc.).

3. Apply the appropriate coding classification/nomenclature and/or clinical terminology system.

4. Explain your medical nomenclature assignment and application with supporting reference(s).

Reference no: EM133477980

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