Wiki Derm visit. Rash with dog bite mentioned.

[betsyt2597]

We had this patient in our office recently. Chief complaint is the rash, but he mentions a dog bite and the doctor prescribed a prescription. Below is the chart note. Is this sufficient documentation for the dog bite or should there be more documentation, such as location on the body, if it was treated by a different physician or self treated?? Any insight would be appreciated.


HPI: This is a 68 yr old male who comes in for a chief complaint of rash, located on the axillae. The rash is itchy and red and moderate in severity. The rash has been present for weeks. Pertinent negatives include: no joint aches, no blisters, no diarrhea, and no cough. He reports no household contacts with similar rash, no new medications and no new personal care products. He is not currently on any treatment.
EXAM:An examination was performed including the scalp (including hair inspection), head (including face), inspection of conjunctivae and lids, lips but not teeth and gums, neck, chest, abdomen, back, right upper extremity, left upper extremity, right lower extremity, left lower extremity, genitalia, groin, buttocks, and inspection and palpation of digits and nails.
General appearance of the patient is well developed and well nourished.
Orientation: alert and oriented x 3.
Mood and affect in no acute distress.
Findings in the above examined areas were normal with the exception of the following exam descriptions below:

Impression/Plan:
1. Irritant Contact Dermatitis (L24.9)
Plan: Counseling.
I counseled the patient regarding the following:
Irritant Contact Dermatitis Skin Care: Avoiding harsh chemicals, prolonged water exposure and wearing gloves can all help improve irritant contact dermatitis. Applying moisturizers regularly will also help reduce irritation. Topical steroids can help in more advanced cases.
Expectations: Irritant Contact dermatitis can persist unless contact with irritants in the environment are eliminated. Sometimes, patch testing is necessary to exclude an allergic contact dermatitis. Contact office if: your dermatitis worsens or fails to improve despite several weeks of treatment.
Plan: Prescription.
betamethasone valerate 0.1% lotion TP Sig: Apply 2 times a day as needed (1 refill)

2. Dog Bite- dog bite occurred 6/2/17
Initial visit (W54.0XXA)
Puncture wounds

Plan: Prescription.
mupirocin 2% topical ointment TP Sig: Apply up to 3 times a day (1 refill)
3. MIPS
Plan: MIPS Quality.
Quality 110 (Influenza Immunization): Influenza immunization not administered because patient refused.

Follow up PRN

 

[ellzeycoding]

The ICD-10 code is correct as it's a general dog bite code and not site-specific.

The more detail, the better. If there is a puncture wound, infection, or other evidence of the bite, then site (severity) would be helpful down the road. Think history of present illness... location, duration, severity, etc.

If the patient was bitten by someone else's dog, and sued the dog's owner, medical records could be requested. Documentation of location and level of injury would be relevant in the case. Just thinking out loud here.

You mentioned another provider. Was the patient referred by a different provider for the dog bite? If so, then you would document the referring provider and a follow-up report should be sent as a result of the consult.