# ? Rov and sov



## HBULLOCK (Sep 15, 2010)

THE DOCTOR WANTS ME TO CHARGE FOR THE ROV AND FOR AN SOV.  I DON'T THINK THERE IS ENOUGH IN THIS NOTE TO DO THAT.  WOULD LIKE ANOTHER OPINION PLEASE.

Reason for Visit/ Chief Complaint 
16 yr rov.
chaperone declined.  
Accompanied by Parents
Parental concerns? Y
behavorial issues- ODD. doesn't take responsibility for anything per mom. p's have thrown him out of the house for his behavior and arguing. fa thinks he is much better when he is on the meds.
not taking concerta- refuses.p's having difficulty coping with him.  
drinking and urinating a lot in past year- gets worse. 


Vital Signs 
AGE 16y6.7m
BLOOD PRESSURE 114/68 R Arm
BLOOD PRESSURE (%) 29/51
HEIGHT 72.75 in
HEIGHT (%) 92
WEIGHT 171.2 lb
WEIGHT (%) 87
BMI 22.8
BMI (%) 72

Interval History 
Illness/Injury since last vist? N
Specialty appointment since last visit? N
Hospitalization, Sugery, ER, Urgent visit since last visit? N

Family History 
Family consists of: Mother; Father; Siblings
bro and sister
Infectious Diseases Y
legionnaires disease at 52. died of lung disease at 81. mgf
Asthma N
Deafness N
Eye N
Cardiac Y
mgf- valve replacement.
GI N
GU N
Endocrine Y
pgm,mgf-dm
Psychiatric N
Mental Retardation/ Developmental Delay N
Neurological Y
mgm-stroke- died of stroke at 72.
JRA Y
mom RA, pgf also
Skin N
Congenital N
Cancer N
Allergies N
Other Y
pgf-copd 
Social History 
Household changes? 
moved in billerica. may 09. 
Smokers in environment? Y
fa
Pets in environment? Y
2 dogs
Firearms in environment? Y
fa goes to gun range.locked
TB Risk Status? Low
Violence in home? N
Financial instability? N
Education Attends school; Has career plans
mechanic
Substances 
Use tobacco? Current
5 / day
Use alcohol? Current
occ beer few few times a month. 
Use drugs? Current
blunt mj weekends. 
Sexual History 
Age first sexual activity 
16
Lifetime number of sexual partners 
1
Partners opposite sex? Y
Partners same sex? N
Contraception used? Y
condoms
STDs? No

Education and Activities 
Grade Level 11th Grade
School Type Public
Name of School 
billerica hs. 
School Performance Fair
Weaknesses 
chemistry- failed
refused summer school. 
Sports Yes
baseball- town league
Music Yes
guitar, bass. 
Dance No
Clubs No
Drama No
Hobbies Yes
bikes 
Diet 
Rate eating habits Poor
Food groups? Meats; Vegetables; Fruits; Grains; Dairy
Other liquids? Milk; Juice; Water; Soda
discussed. 
Comments 
junk food
Sleep 
Sleeps through night? Y
Sleep concerns? N

Safety 
The following safety items were discussed (age approp.): helmet for bicycle-rollerblades-skiing; seat belts; driving

Physical Exam 
General Appearance 
WDWN, NAD
Skin 
No cyanosis, rash, abnl pigmented lesions, striae, intertrigo, hirsutism 
Head 
Normocephalic, atraumatic, no facial dysmorphism
Eyes 
PERRL, red reflex present, EOM normal, corneal light reflex normal
Ears 
NL canals, TMs clear with normal landmarks
Nose 
NL shape, no discharge
Mouth 
NL tongue, mucosa, dentition
Throat 
NL tonsils.  No petechiae, exudate
Neck 
Supple, no adenopathy or masses, no thyromegaly 
Heart 
RRR, no murmur, S1 & S2
Lungs 
Clear to auscultation, no rales or wheezes
Abdomen 
Soft, non-tender,  no masses.  Liver/spleen not enlarged.  NL bowel sounds.
External Genitalia 
NL external genitalia. No hernia. No discharge
Breast 
No masses or discharge bilaterally
Extremity 
No deformity with full range of motion, no poly/syndactyly, no edema, no genu varum/valgus
Neurological 
Age appropriate reflexes present. DTRs symmetric/non focal
Gait 
NL gait, without limp, in-toeing
Back 
Flexible without scoliosis
Assessment Routine well child care EXCEPT:
adhd,behavioral problems. ODD.  
polydipsia, polyuria
crafft=u-2

Plan 
Plan 
u/a and ua for chlam and gc
blood sugar.
MH list given= recommended family therapy. 
discussed with p's and pt
Discussed diet, activity, screen time and counselled about weight management. 5/2/1/0.
recommended going back on the concerta- he thinks he will take it again.will decide soon.  
Next appointment 
1 y
if starts concerta will rto for f/u as usual. 
Allergies 
NKA

I THOUGHT WE COULDN'T USE PARTS OF THE ROV AS PART OF THE SOV SINCE THAT WOULD BE DOUBLE-DIPPING. ANY THOUGHTS??  THANKS


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## Colliemom (Sep 16, 2010)

What is an ROV and SOV?


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## HBULLOCK (Sep 16, 2010)

routine office visit and sick office visit


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## LLovett (Sep 17, 2010)

behavorial issues- ODD. doesn't take responsibility for anything per mom. p's have thrown him out of the house for his behavior and arguing. fa thinks he is much better when he is on the meds.
not taking concerta- refuses.p's having difficulty coping with him. 
drinking and urinating a lot in past year- gets worse. 

recommended going back on the concerta- he thinks he will take it again.will decide soon

Based on this info alone you could support a 99213 in addition to your well care visit. 

I will also state I am a bit confused by some of the abbreviations used in this note. If you are using non standard abbreviations make sure you have a master list explaining what they are on file in case of outside audit.

Laura, CPC, CPMA, CEMC


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## HBULLOCK (Sep 17, 2010)

Which abbreviations are unusual??  I'd like to have them checked incase of audit. I'm used to these doctors style so i didn't realize the abbreviations they are using aren't common. Thanks alot:d


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