HS292 Unit 2 Gout Visit Record Abstraction Example

Reviewed by Elspeth Marlowe, MSN, RN Billing and Coding Practicum Purdue University Global Free custom sample in 24 to 48h

In this HS292 Unit 2 record abstraction exercise, one composite office visit for a gout flare in the left great toe is sorted into what can be coded, what cannot and what still needs asking, before any code is chosen. Purdue Global HS 292, the Billing and Coding Practicum in the Associate of Applied Science in Health Science, treats abstraction as its own graded step. The note appears with nine numbered lines, and every entry on the sheet cites its line: the flare and its treatment, stable hyperlipidemia with a refill, cigarette smoking with timed counseling, the services and the side. A kidney stone history and a septic joint the provider excluded are kept visible but marked not for coding. A thiazide diuretic started last month raises an open question, answered with a compliant multiple-choice query.

CourseHS292 Billing and Coding Practicum
UnitUnit 2
Paper typeRecord abstraction exercise
LengthAbout 610 words, 5 pages double-spaced
FormatAPA 7 student paper
SchoolPurdue University Global
ProgramAssociate of Applied Science in Health Science
UpdatedOctober 2026

Free sample paper for HS292 Unit 2

1

Codable, Not Codable, Still to Ask: A Unit 2 Record Abstraction Exercise on an Office Visit for a Gout Flare

[Student Name]

Purdue University Global

HS292: Billing and Coding Practicum

Unit 2 Record Abstraction Exercise

[Instructor Name]

[Date]

The office note and patient are composite; the coding guidelines and clinical guideline cited are real.

What this part is doingPromising line numbers in the lead tells the grader that each entry can be traced to the record rather than taken on trust.
2

The Note, With Numbered Lines

1. Chief complaint: pain and swelling, left great toe, three days.

2. History: woke with severe pain; cannot wear a shoe; no injury.

3. Past history: hyperlipidemia; kidney stone in [year]; hypertension.

4. Medications: atorvastatin 20 mg daily; hydrochlorothiazide 25 mg daily, started last month.

5. Social: smokes about one pack per day.

6. Exam: left first metatarsophalangeal joint red, warm, swollen, exquisitely tender. Temperature 37.4 C.

7. Assessment: acute gout flare, left great toe. Septic joint considered; afebrile, single typical joint, history classic; not suspected.

8. Plan: [medication] course for the flare. Hyperlipidemia stable, atorvastatin refilled. Counseled on smoking cessation, about [5] minutes.

9. Plan continued: recheck in two weeks; uric acid level once the flare settles.

Abstraction Sheet

Reason for visit. Pain and swelling of the left great toe for three days (line 1). The provider's conclusion is an acute gout flare of the left great toe (line 7).

Conditions addressed. Gout flare, treated with a medication course (lines 7 and 8). Hyperlipidemia, assessed as stable with a medication refill (line 8).

Status factors. Current cigarette smoking, about one pack a day (line 5), with documented cessation counseling of about [5] minutes (line 8).

Services. Office visit with history, examination and medical decision making (lines 1 to 9). Smoking cessation counseling with time recorded (line 8). Uric acid level ordered for a later date, not performed today (line 9).

Laterality and site. Left side, first metatarsophalangeal joint, which the code set groups under ankle and foot (lines 1, 6 and 7).

Not for coding. Kidney stone history (line 3): listed but not evaluated or addressed, so it does not meet the outpatient rule that coexisting conditions are reported when they require or affect care at the visit (National Center for Health Statistics, 2025). Septic joint (line 7): considered and excluded, and a ruled-out condition is not coded. Hypertension (line 3): listed in past history with no assessment today, so it is held, with a note that the diuretic in line 4 is presumably for it.

Every entry above carries a line number; an entry that could not be given one would be an inference, not an abstraction.

Still to ask. Hydrochlorothiazide was started last month (line 4), and thiazide diuretics are a recognized contributor to gout (FitzGerald et al., 2020). The provider never connects the two. Whether this flare is drug-induced changes the code category, and only the provider can say so. A query is drafted below.

What this part is doingSeparating the open question from the not-for-coding list shows the difference between information that is irrelevant and information that is unresolved.
3

Draft Query

Dr. [Name], the note for [date] documents an acute gout flare of the left great toe and lists hydrochlorothiazide 25 mg daily, started last month. Based on your clinical judgment, can the cause of this gout flare be further specified? Please document your response in an addendum. Options include drug-induced gout, idiopathic gout, other or unable to determine. The query follows the multiple-choice format that published query practice guidance allows, with clinically reasonable options drawn from the record (American Health Information Management Association & Association of Clinical Documentation Integrity Specialists, 2022).

What this part is doingListing other and unable to determine among the options keeps the query from steering the provider toward the more specific answer.
4

Sorting Rule Used

Each statement was placed in one of three groups. Codable means the provider concluded it and it affected care today. Not codable means it was ruled out or not addressed. Still to ask means the record raises a question only the provider can answer.

5

References

American Health Information Management Association & Association of Clinical Documentation Integrity Specialists. (2022). Guidelines for achieving a compliant query practice (2022 update). American Health Information Management Association.

FitzGerald, J. D., Dalbeth, N., Mikuls, T., Brignardello-Petersen, R., Guyatt, G., Abeles, A. M., Gelber, A. C., Harrold, L. R., Khanna, D., King, C., Levy, G., Libbey, C., Mount, D., Pillinger, M. H., Rosenthal, A., Singh, J. A., Sims, J. E., Smith, B. J., Wenger, N. S., . . . Neogi, T. (2020). 2020 American College of Rheumatology guideline for the management of gout. Arthritis Care & Research, 72(6), 744-760. https://doi.org/10.1002/acr.24180

National Center for Health Statistics. (2025). ICD-10-CM official guidelines for coding and reporting FY 2026. Centers for Disease Control and Prevention.

Reading the HS 292 Unit 2 instructions

The second unit of the practicum commonly asks you to abstract a record: read a note and record the facts a coder will need, without yet assigning codes. Instructors look for every relevant statement captured, each tied to its place in the note, and for a clear separation between codable facts, facts that should not be coded and questions the record leaves open. Showing excluded items with a reason, rather than omitting them, proves they were read. Many sections reward a drafted query for any open question, written so that it does not lead. Headings that follow the order a coder reads a visit make the sheet easy to audit. Citing the guidelines for exclusions and a clinical source for the open question strengthens the work.

How the HS 292 Unit 2 example is put together

The exercise reproduces the note with numbered lines, from chief complaint to plan. The abstraction sheet follows under headings for reason for visit, conditions addressed, status factors, services, laterality and site, not for coding and still to ask. Each entry carries line numbers. The not-for-coding section explains why the kidney stone history, the excluded septic joint and the unassessed hypertension stay off the claim. The highlighted sentence states the rule that an entry without a line number is an inference. The still-to-ask section cites rheumatology guidance on diuretics and gout, and a draft query offers drug-induced, idiopathic, other and unable to determine as options.

Reading the HS292 Unit 2 grading rubric

Abstraction exercises are assessed on completeness, traceability to the record, correct sorting, quality of any query and organization. Correct sorting usually decides the grade, because the exercise exists to show that a coder can tell a codable fact from an excluded or unresolved one. Completeness rewards capturing services and status factors as well as diagnoses. Traceability earns credit when each entry cites its line. A query should be compliant, with options drawn from the record and an escape option. Headings in a coder's reading order help the grader follow the work. Citations of the guidelines and a clinical source complete the expectations. Sheets that quietly drop excluded items lose points even when the codable list is right.

HS292 Unit 2 help: mistakes that cost points

Students often jump ahead to codes, which skips the sorting the unit is grading. Another frequent problem is listing the kidney stone history or the excluded septic joint as conditions to code. Some sheets omit tobacco use and counseling, which are reportable when documented. Others notice the diuretic but assume the gout is drug-induced, making a clinical judgment that belongs to the provider. Queries that offer only one option, or that hint at the preferred answer, lose marks. If your instructor posted another visit, perhaps an asthma visit or a diabetic follow-up, share it, and our coders can draft an abstraction sheet with line references and a compliant query.

Get an HS292 Unit 2 example written to your instructions

An abstraction depends entirely on its source, so the office note or record set from your Unit 2 exercise comes first, then any abstraction form the course provides and the rubric. Each fact returns sorted and tied to its line, with gaps flagged rather than guessed. Nothing is charged for the first custom sample, delivered in 24-48h. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.

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HS292 Unit 2 questions, answered

Why does the abstraction contain no codes?

Because in many HS292 sections the abstraction is graded as its own step, and adding codes invites the grader to mark the selection instead of the sort. Where your instructions ask for codes on the same sheet, the abstraction still comes first and the codes sit in a separate column, each pointing back to an abstracted fact rather than to the note directly.

Is tobacco use really a codeable fact?

Where the provider documents it, yes. Tobacco use or dependence and the counseling given are reportable when the note records them, and they are among the facts new abstractors most often skip because neither is the reason for the visit. The sample lists status with its own line reference so it cannot be mistaken for an assumption drawn from the patient's history.

What makes an open question different from an error?

An error is a fact misread; an open question is a fact the record does not supply. The diuretic case is the second kind, since the note gives the drug and the flare but no link between them. Recording that gap, with the line numbers that create it, is the correct answer at the abstraction stage. Deciding the cause without the provider would turn a gap into an error.

Where can I find a free HS292 Unit 2 sample paper?

The complete Unit 2 record abstraction exercise is on this page, sorting a gout visit's statements into codable, not codable and still to ask.

Is a condition the provider ruled out ever coded?

No. A condition considered and excluded, such as the septic joint here, is not coded. The symptoms or the confirmed diagnosis are reported instead.