I am questioning if I can give credit for the diagnosis, "cigarette abuse" in my medical decision making for my E & M level of service. Here is an example of the A/P:
Assessment/plan:
1. Lung Cancer. We will continue afatinib and reassess in two weeks.
2. Cigarette abuse, ongoing.
3. Fatigue, ongoing without nutritional deficiency
4. CINV. I have renewed his prescription for Phenergan. We will monitor. Liberal fluids advised.
The patient didn't have smoking cessation counseling. It is just listed due to effect of primary diagnosis of Lung Cancer.
Thanks!
Assessment/plan:
1. Lung Cancer. We will continue afatinib and reassess in two weeks.
2. Cigarette abuse, ongoing.
3. Fatigue, ongoing without nutritional deficiency
4. CINV. I have renewed his prescription for Phenergan. We will monitor. Liberal fluids advised.
The patient didn't have smoking cessation counseling. It is just listed due to effect of primary diagnosis of Lung Cancer.
Thanks!