Evaluation and Management

Management and Evaluation
Relevant Data for DSM-5 and ICD-10 Coding
All of the symptoms that the patient is experiencing are included in the relevant information for DSM-5 and ICD-10 coding. Physical changes or psychological effects on mental functioning may be present as symptoms. The data should include the behavioral changes that the patient is experiencing as a result of the illness. The severity of illness symptoms varies from patient to patient (Gribsholt et al., 2019). Identifying the relevant information is critical in arriving at an accurate diagnosis. Changes in behavior should be made with the patient’s medical history in mind. Assessing a patient’s health will reveal their illness and point them in the right direction for treatment. A healthcare worker should document everything required to diagnose mental illnesses. A psychological evaluation, lab tests, and physical exams may be required to diagnose mental conditions (Gribsholt et al., 2019). The data will be crucial in improving the accuracy of the diagnosis.
The Scenario’s Relevant Documentation Is Missing
The scenario is missing important information that is necessary for diagnosis. Minor symptoms such as headaches are among the missing data. Misdiagnosis can occur when vital information is missing (Southern et al., 2017). The color of the vomit is another piece of information that is missing. The color of the vomit indicates the cause, potential illness, and appropriate treatment method. The scenario does not specify whether or not the patient is in pain.
The missing relevant information is important because it can aid in narrowing down to specific coding and billing. Inadequate information can make it difficult to obtain the correct codes (Southern et al., 2017). Nurses can make mistakes during diagnosis if they have insufficient information about a patient.
Enhancing Documentation to Aid Coding and Billing
Nurses must constantly improve the documentation process in order to achieve accurate coding and billing. One of the enhancements is to ensure that all diagnostic details are provided. The full details will provide detailed data for nurses and physicians to use in making diagnostic decisions, billing, and coding. Comprehensive documentation will assist a multidisciplinary team in making sound decisions (Gribsholt et al., 2019). The complete documentation should assess a patient’s health, including subjective and objective data. The information, including the patient’s medical history, will be used to determine the diagnostic tools and tests that will be performed. Nurses and doctors should use electronic health records to determine when tests or medication should be performed. The information will be used to determine whether the patient has a similar infection or an independent illness from previous diseases.

S. B. Gribsholt, L. Pedersen, B. Richelsen, and R. W. Thomsen (2019). In Danish hospitals, the validity of ICD-10 diagnoses of overweight and obesity was investigated. Clinical Epidemiology, vol. 11, no. 845.
D. A. Southern, B. Burnand, S. E. Droesler, W. Flemons, A. J. Forster, Y. Gurevich,… and W. A. Ghali (2017). Using administrative hospital data, derive ICD-10 codes for patient safety indicators for large-scale surveillance. 252-260 in Medical Care.