Comprehensive H&P for D. A. Tyler Martin, a third-year medical student on a family practice clerkship, was directed to obtain a comprehen sive H&P of a new patient: D. A. D. A. recently moved to your city and has never been seen at this practice. She comes in today to establish care, and she is complaining of a cough. Following is the student’s documentation of the comprehensive H&P. As you read it, keep in mind the requirements set forth in the 1997 Guidelines of Doc umentation for Evaluation and Management by CMS for information that should be included in a medical record. Refer to the H&P to answer the questions that follow. 1. Does this document meet the CMS guidelines for documentation of a comprehensive H&P? Why or why not? 2. Critically analyze the H&P and list any errors. 3. Did any questions come to mind that you are unable to answer after reading the H&P? 4. Are the diagnoses listed in the Assessment section reasonably supported by the history? Why or why not? 5. Did you identify other differential diagnoses or conditions that could be included in the assessment? If so, list. 6. Is the plan reasonable based on the assessments listed? Why or why not
[Answered]: Comprehensive H&P for D
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