Part 2- Turning in your final treatment plan and Analysis
The final treatment plan will include the primary diagnosis, diagnostic testing recommended by National Guidelines. Medications, interventions, education, labs, follow up, referrals. After completing the treatment plan include the following sections in a large area called ANALYSIS:
Pathophysiology and Pharmacology: For the primary diagnoses in the case, write a brief summary of the underlying pathophysiology and tie pharmacological treatment chosen in the reversal or control of that pathology.
Additional analysis of the case: This includes national guidelines that were or should have been used to make diagnosis or treatment and review how they applied or how care was unique but based in guidelines.
Follow-up/Referrals: This means how the patient was doing when seen a second time if this applies. This would be their response to your plan of care. OR when Follow up will occur and what actions will be taken on the follow up visit. Referrals if indicated.
Quality: Include anything that should have been considered in hindsight or changes you would make in seeing similar patients in the future with the same complaint, history, exam, or diagnosis.
Coding and Billing. Any or all CPT and ICD-10 codes that should have been used (List them and name them only.