The document meets the CMS guidelines due to several reasons. CMS is focused on ensuring
that there is collaboration between the patients and the healthcare providers to come up with
understanding of the medical condition that the former is going through in a bid to get the
solution to the problem. One important thing is that the source of information is reliable. The
information comes from the patient through the face to face office visit. The fact that the
information that is contained in the document is a result of the collaboration between the
patient and the doctor means that the diagnosis meets the CMS guidelines with the aim of
finding effective solutions to the health issues that the patient is facing. The physician then
uses the information to come up with a treatment schedule that will be effective for the
patient ("Home – Centers for Medicare & Medicaid Services," 2019).
The strengths of the H&P is that it contains the information that will help in the identification
of the medical issue that the patient is suffering from hence find the appropriate interventions
that can be applied in the process.The other strength is that the physician collects the
important information directly from the patient hence can use it appropriately for finding the
best treatment strategy that can be used in the process. Some of the weaknesses identified
include the fact that the physician has at one point relied on the word of mouth presented by
the present, a situation that may cause errors in the diagnosis and the subsequent treatment
process. The doctor need to request some form of document from the patient and should also
get information from a close relative as a way of finding the accurate information about the
medical history of the family as well as that of the patient as a way of coming up with a more
comprehensive and accurate diagnosis that will be important for treating the patients. The
other weakness is that the antibiotics that the patient used recently is not well known a
situation that may make the doctors not to be sure if she used the right medicine or not. It is
clear that there is insufficient documentation with regards to the health of the patient which is
a situation that makes the process of coming up with the correct diagnosis to be challenging.
The doctor has also identified that she is suffering pneumonia but has not specified the
microorganism that caused the disease.
There are some questions that came in my mind after reading the H & P that I was unable to
answer. One of such questions is why a doctor will treat a patient without making her know
the kind of medicine that she is using. The other question that I ask myself is how careless is
the patient to the point that she is not aware of the drugs that she used and losing the relevant
medical documents in the history that could be used in the future medical diagnosis.
The conditions that are presented in assessment are supported by history. Her past medical
history shows that she has suffered from Hypertension, Bronchitis, Hyperlipidemia, Obesity.
The results of the assessment show that she is still obese, she still has hypertension, she still
has Hyperlipidemia and she has asthma which may have developed from the respiratory
complications that she has. She also has asthma, a disease that her son is also living with.
The other diagnosis that is supposed to be done is an attempt to understand the cause of the
obesity and what can be done to deal with accordingly.
A List the ICD-10 code for each of the following
Moderate persistent asthma with (acute) exacerbation: _ Code J45.41 ____
Pneumonia, unspecified organism: __ J18.9
Essential (primary) hypertension: ___ R03. 0 ___________
Hyperlipidemia, unspecified ___ E78.5 ___________
Obesity: ___ E66.9 ___________
It is appropriate to include the ICD-10 code for pneumonia when billing for this visit because
of the fact that it is needed for the diagnostic specificity and morbidity classification in the
U.S. It will help in the ongoing research about the diseases to come up with the treatment for
the diseases ("2020 ICD-10-CM Codes," n.d.).
The plan is not reasonable according to the assessment because of the fact that it does not
address all the diseases that haver been identified in the case study. For instance it does not
contain the intervention for treatment of obesity. The people with hypertension need an
exercise procedure or plan that will enable them to deal with the disease. The plan does not
have an exercise schedule and some other important interventions that would be useful to the
patients. If the patient wants to see an improvement in the treatment, she should work on her
obesity because it potentially lead to the other lifestyle diseases such as diabetes and at times
it may increase the risk of having a stroke. It is therefore important to use the treatment
strategies to prevent the other diseases that may affect the patient in the future. The plan is
therefore not reasonable because it will not effectively lead to the treatment of the diseases
that have been identified in the case study ("2020 ICD-10-CM Codes," n.d.).
There are several patient education strategies that are relevant to the case study. One is the
determination of the learning style of the patient as a way of ensuring that she is learning
effectively. The other strategy is to stimulate the learning interest in the patient. The patient
who is interested in the learning process will definitely look for ways of understanding the
content that she is being taught for the benefit of the patient and the society in general. The
other learning strategy that is relevant to the current study is making use of technology in the
learning process. Technology also helps in the other strategies such as exercising and the
application of the other methodologies that will help in dealing with the problem of obesity.
The individuals should undergo diagnosis as a way of knowing the diseases that they are
suffering from then look for treatment. In the case of hypertension, the patient is supposed to
live an active lifestyle as a way of dealing with the disease and preventing the cases of the
condition worsening. The treatment provided should be able to deal with both the disease and
the symptoms as a way of ensuring that the patient lives a comfortable life ("Section 2.
Recommendations for Adults | Agency for Healthcare Research & Quality," n.d.).
2020 ICD-10-CM Codes. (n.d.). Retrieved from
Home – Centers for Medicare & Medicaid Services. (2019, October 15). Retrieved from
Section 2. Recommendations for Adults | Agency for Healthcare Research & Quality. (n.d.).
Retrieved October 17, 2019, from