Certified Risk Adjustment Coder (CRC)

What must be included in the assessment of a patient with pulmonary embolisms?

1. Diagnosis codes only

2. A full detailed history

3. Assessment and plan of care

4. Demographic information

The correct answer is: Assessment and plan of care

In the assessment of a patient with pulmonary embolisms, including an assessment and plan of care is essential for several reasons. Firstly, the assessment incorporates the clinician’s evaluation of the patient’s current health status, any symptoms present, and how the pulmonary embolism is affecting their overall condition. This comprehensive assessment allows healthcare providers to determine the severity of the embolism and tailor treatment accordingly. The plan of care outlines the proposed interventions, including immediate medical treatment, follow-up care, and any additional testing needed to monitor the patient’s condition. This is critical in managing the risks associated with pulmonary embolisms, which can lead to serious complications if not addressed promptly and effectively. While a full detailed history, demographic information, and diagnosis codes are important components of a complete patient record, they do not encompass the immediate need to address the patient's current condition or the strategic approach to their management, which is why the assessment and plan of care are key in this scenario.