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Case 4 Discharge Summary ADMISSION DATE: 5/6/xx DISCHARGE DATE: 5/8/xx HISTORY: This patient is gravida 2, para 1 and was seen in my office for her prenatal visits, which were uneventful. She was admitted with a history of contractions every 3 to 5 minutes. Cervix was 100% effaced and 9 cm dilated. HOSPITAL COURSE: The patient's water broke at 2 a.m. and after 3 hours the patient delivered a baby girl with an Apgar score of 8 at 1 minute and 10 at 5 minutes. Postpartum care was uneventful. The patient was discharged 2 days later. INSTRUCTIONS TO PATIENT: Diet as tolerated. Tylenol as needed for pain. She is to follow up in my office in 2 weeks. ICD-10-PCS Code Assignment:

          Case 4 Discharge Summary

ADMISSION DATE: 5/6/xx
DISCHARGE DATE: 5/8/xx

HISTORY: This patient is gravida 2, para 1 and was seen in my office for her prenatal visits, which were uneventful. She was admitted with a history of contractions every 3 to 5 minutes. Cervix was 100% effaced and 9 cm dilated.

HOSPITAL COURSE: The patient's water broke at 2 a.m. and after 3 hours the patient delivered a baby girl with an Apgar score of 8 at 1 minute and 10 at 5 minutes. Postpartum care was uneventful. The patient was discharged 2 days later.

INSTRUCTIONS TO PATIENT: Diet as tolerated. Tylenol as needed for pain. She is to follow up in my office in 2 weeks.

ICD-10-PCS Code Assignment:

Added by Bianca W.

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