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Health Record Documentation Assignment Paper Domain 1: Data Governance, Content, and Structure 1.15 Special health record documentation requirements Competency 1.4 1. You have been asked to audit a pediatric group's medical records. In addition to verify ing the the tasked with ensuring that all relevant documengation, appropriate E\&M record. present in the record and checklist that follow a. Use the scenario and the B G that the child has been crying and pull bulging tympanic membranes indicative of fluid buildup. ver. Otoscopic examination revealed buly infection. Script e-faxed to pharmacy. Amoxicillin prescribed for var isit: 99202 T full-term, vaginal birth. Uncomplicated pregnancy, natural chile. 10/09/18 Timothy had an uneventful, APGAR score at birth 8, repeat APGAR 10. BIRTH HISTORY birth.

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No forceps used in delivery. AP PERSONAL, SOCIAL, AND FAMILY HISTOR who is four years old. Parents are married. Non-smoking $11/10/18$ Second child, one older sister who is four yeare after mother's maternity leave ends in three environment. No pets in the home. Will ate birth. NUTRITIONAL HISTORY $11/10/18$ Timothy is breastfed initially. $12/13/18$ Breastfeeding continues. $2/16/19$ Breastfeeding continues. $7/15/19$ Infant eats rice and oatmeal cereal, variety of fruits. No reactions noted to new foods. $4/18/19$ Cereal has been introduced into diet, rice. Well-child visit. No problems. Child thriving. Growth appropriate. OFFICE NOTE: $11/10/18$ Well-child visit. No problems. Growth appropriate. First set of vaccines administered. OFFICE NOTE: $12/13/18$ Well-child visit. No problems. Growth appropriate. Developmental milestones met. Second set of varem OFFICE NOTE: 2/16/19 administered. Well-child visit. No problems. Growth appropriate. Developmental milestones met. Third set of rwe OFFICE NOTE: 4/18/19 administered. MEDICATIONS 7/15/19 Amoxicillin BID for 10 days. CHECKLIST Office note-well-child or medical issue Birth history Nutritional history Personal, social, and family history Growth and development record Immunizations Medications Discharge status Health Record Documentation Assignment Paper