After reviewing Jane Dare’s chart, which of the following code assignments would be appropriate for

After reviewing Jane Dare’s chart, which of the following code assignments would be appropriate for this case? Z88.2, J18.9, I50.9 I50.9, J90, Z88.2, J18.9 I50.9, J90, R06.00, J18.9, Z88.2 I50.9, J18.9, Z88.2 Admitting Diagnosis (Within 24 Hours) ICD-9-CM CODES Principal Diagnosis Secondary Diagnoses Complications Operative Procedures (Date & Title) Discharged Alive ____ Died ____ Autopsy Yes ____ No ____ Physician Signature This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental. © 2003. American Health Information Management Association. All rights reserved. ADMISSION SUMMARY SHEET Congestive heart failure, left pleural effusion, pneumonia This 73-year-old female presents to ER C/O of SOB x 3-4 days. Not sleeping well. Increase pedal edema. Denies cough or fever. Has history of atrial fibrillation severe regurgitation from tricuspid and mitral valve dysfunction. Allergy: Sulfa Medications: 1. Capoten 25 mg po tid 2. Furosemide 40 mg po qd 3. Digoxin 0.125 mg po qod 4. Nortriptyline HCL 10 mg po qhs 5. Tylenol 325 mg tabs prn for pain 6. KLOR 10 mg qd 7. Milk of Magnesia 30 cc po qd prn Family History: Noncontributory. Social History: Has been living with husband. Negative for alcohol. Ex-smoker for many years. PHYSICAL EXAMINATION: Pleasant, sitting upright. HEENT: Difficult fundoscopic exam. Neck: Supple with positive venous distension CNS: Rate 104, irregular with gallop. Crackles in left lower lobe. Right is dull. Abdomen: Benign. Genitalia: Normal except for red sacral area. No obvious breakdown. Extremities: 3+ pitting edema to knees. Neurological: Appropriate. Alert. Chest x-ray: Left pleural effusion, congestive heart failure, pneumonia. Assessment: Congestive heart failure, left pleural effusion, pneumonia Plan: Admit. Diurese IV antibiotics Blood cultures and sputum if possible O2 Bedrest RESIDENT ASSESSMENT PROTOCOL Document problems, complications, and risks factors; the need for referral to appropriate health professionals; and the reason for deciding to proceed or not to proceed to care planning. RAP Problem Area # 1 Delirium: Resident triggers delirium because of deterioration of cognitive skills and deterioration of communications skills. Causal factor of the RAP appears to be her cardiac diagnosis. She also appears to be depressed and very unhappy. Will be seen by Dr. Archibald M. Graham on nursing home rounds. Based on above documentation, will proceed with care planning Cognitive Loss/ Dementia: Resident triggers cognitive loss/dementia because of mild, short term memory loss (forgetful) and some decision making problems. She is alert and oriented, but sometimes will forget the time or wonder why she is here. She has been complaining since admission regarding her room (too small, too humid, too hot, etc.) She swears at the staff and other residents. She cries easily. Factor of triggered RAP appears to be sadness, unhappiness over being away from her husband. She had no diagnosis of dementia at this time. Will be seen by Dr. Archibald M. Graham on nursing home rounds. Based on above documentation, will proceed with care planning. RAP Problem Area # 3 Nutritional Status: Resident is on a NAS diet and has several food complaints/dislikes. Causal factors appears to be diagnosis of CHF. Registered Dietitian will follow. Proceed with care planning Communication: Resident has mild impairment with cognitive skills for daily decision making. She often refuses to sleep in her room. States the room is too hot, too cold, too humid, too small, etc. Staff have found her sleeping on the floor of the guest room, sleeping in a chair in the guest room, etc. She make her needs known to staff. Has tried to refuse meds, and ADL assistance. Will be seen by Dr. Archibald M. Graham on nursing home rounds ADL Functions/Rehabilitation Potential: Resident has self care deficit. She needs physical assist of 1 staff with dressing and bathing. She receives physical assistance of 1 to transfer at least q. d. She has been incontinent of BM almost q.d. Staff assists to bathroom and on and off toilet. She is too weak and SOB to be completely independent at this time. Causal factor appears to be end-stage cardiomyopathy. Resident will be seen by Dr. Archibald M. Graham on nursing home rounds. Based on the above documentation, will proceed to care planning. Mood State: Resident is very unhappy here. Cries often “I want to go home”. States that she can’t make it another day without her husband. Many complaints about the staff, food, other residents, etc. Causal factor appears to be sadness due to being apart from her husband. Resident will be seen by Dr. Archibald M. Graham at nursing home rounds. Based on above documentation, will proceed with care planning. Behavior Problems Resident is unhappy with nursing home placement. Has many complaints, such as the room is unfit to live in, staff are no good, and the food is not good. Swears at the staff and other residents. The resident has actually hit staff members and refuses to sleep in her room. Causal factor appears to be anger/adjustment problems. She has severe end-stage cardiomyopathy. Family states that she has been this way all her life. Resident will be seen by Dr. Archibald M.Graham at nursing home rounds. Based on above documentation, will proceed with care planningFalls: Resident is at risk for falls based on the fact that she takes psychotropic medications. She has not fallen since she has been here. She needs assistance of 1 to transfer and ambulate. In the wheelchair she must be pushed to and from all locations as she becomes SOB if doing it herself. No restraints are being used. No complaints of vertigo, etc. Causal factors appear to be triggered by psychotropic drug usage. Based on above documentation, will proceed with care planning. Primary Diagnosis: Congestive heart failure, severe end stage ischemic cardiomyopathy. PT: Evaluate and gait training ambulation with appropriate assistance device. Utilizes front wheeled walker with assistance of 1-2. Strength training, bed mobility and transfer training. Rehab potential fair. INDICATION: CHF, pleural effusion, pneumonia. FINDINGS: PA and lateral chest compared with 6-7-xx. There has been slight improvement in the left lower lung field infiltrate. Small bilateral pleural fluid collections persist. Stable cardiac and mediastinal silhouettes. CONCLUSION: Slight interval improvement of the appearance of the chest. WCR/bc

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