I have trouble agreeing with CC for this note. I've been told as long as there is organ failure he does not need to describe in more detail. Can someone give me an opinion on this note please? Recurrent VT -discussed with pt and family the need for cath to rule out active ischemia as a cause of v.t. Managed antiarrythmia (amiodarione) stared beta blocker, arranged cardiac cath and ep eval. Ischemic cardiomyopathy -assessed possible volume overload and began beta blocker. He tells me nothing of the V.T. rate, the next day he was hypotensive...never gave me the bp and billed cc. I feel this is just managing the care. We are a teaching hosp, but his not needs to stand on its own. Iv'e been told I am asking for too much.
A separate patient note I reviewed I feel good about coding he 60 mins of cc. Briefly -MD called to pts room, in V.T. with heart rate at 150 bpm, the MD goes on and on about the care of the patient including the drugs, pace terminated by pacing through device, patient and finally bpm at 70. Includes drugs, the patients mentation and an exam.
A separate patient note I reviewed I feel good about coding he 60 mins of cc. Briefly -MD called to pts room, in V.T. with heart rate at 150 bpm, the MD goes on and on about the care of the patient including the drugs, pace terminated by pacing through device, patient and finally bpm at 70. Includes drugs, the patients mentation and an exam.