btadlock1
Guest
I've posted this note before, but I couldn't remember what was bugging me about it (besides not being able to pinpoint the HPI elements, specifically)...Now I do remember, so I'm posting it again! Pay close attention to the exam and the plan - Would you consider this an E/M, or is it really more of a discontinued procedure? Please help!
Visit Type: Scheduled follow-up
Reason for visit (nurse documentation) 3mo pessary follow up appt and insert Femring
CC: Pt to office for pessary check and insertion of femring. Pt has not been using her vagifem supp as directed.
ROS: Constitutional: No fever, no chills, no weakness.
ENMT: No decreased hearing
Respiratory: No SOB, no cough
CV: No chest pain, no palpitations, no peripheral edema
GI: No nausea, no vomiting, no diarrhea, no constipation, no abdominal pain
GU: cystocele corrected with pessary. No dysuria, no urinary hesitancy
Allergies: Cipro, Cyclobenzaprine, penicillin, sulfa drug
Social History: Alcohol use: denied
tobacco use: none
Recreational drug use: denied
Exam:
Systolic BP: 155 mmHg HI
Diastolic BP: 77 mmHg
Heart rate on monitor: 57 bpm LOW
BP Method: electronic measurements
Weight: 64.410 kg
Height Estimated in: 65 inch
Weight lb: 141.7 lb
BMI: 23.63
General: Alert and Oriented. No acute distress.
Neck: Supple, non-tender, no lymphadenopathy, no thyromegaly.
Respiratory: Lungs CTA. Breath sounds are equal.
GI: Soft, non-tender. Normal bowel sounds.
GU: Normal genitalia for age. Vagina: Mucosa (Atrophy, dryness, vaginal introitus opening smaller due to atrophy. Not able to remove pessary without tearing vaginal opening today.)
Integumentary: Warm, dry. Integumentary exam: Normal for ethnicity.
Psychiatric: Alert and Oriented x4. Cooperative. Appropriate mood and affect.
Diagnosis: Cystocele, Atrophic vaginitis
Plan: Discuss using estrace cream to opening of introitus BID for next two weeks then follow up appt for removal of pessary and insertion of new femring. Pt educated on pessary care and douching and vaginal hygiene. Follow up sooner if problems.
Provider coded as 99213 with primary diagnosis 627.3
Visit Type: Scheduled follow-up
Reason for visit (nurse documentation) 3mo pessary follow up appt and insert Femring
CC: Pt to office for pessary check and insertion of femring. Pt has not been using her vagifem supp as directed.
ROS: Constitutional: No fever, no chills, no weakness.
ENMT: No decreased hearing
Respiratory: No SOB, no cough
CV: No chest pain, no palpitations, no peripheral edema
GI: No nausea, no vomiting, no diarrhea, no constipation, no abdominal pain
GU: cystocele corrected with pessary. No dysuria, no urinary hesitancy
Allergies: Cipro, Cyclobenzaprine, penicillin, sulfa drug
Social History: Alcohol use: denied
tobacco use: none
Recreational drug use: denied
Exam:
Systolic BP: 155 mmHg HI
Diastolic BP: 77 mmHg
Heart rate on monitor: 57 bpm LOW
BP Method: electronic measurements
Weight: 64.410 kg
Height Estimated in: 65 inch
Weight lb: 141.7 lb
BMI: 23.63
General: Alert and Oriented. No acute distress.
Neck: Supple, non-tender, no lymphadenopathy, no thyromegaly.
Respiratory: Lungs CTA. Breath sounds are equal.
GI: Soft, non-tender. Normal bowel sounds.
GU: Normal genitalia for age. Vagina: Mucosa (Atrophy, dryness, vaginal introitus opening smaller due to atrophy. Not able to remove pessary without tearing vaginal opening today.)
Integumentary: Warm, dry. Integumentary exam: Normal for ethnicity.
Psychiatric: Alert and Oriented x4. Cooperative. Appropriate mood and affect.
Diagnosis: Cystocele, Atrophic vaginitis
Plan: Discuss using estrace cream to opening of introitus BID for next two weeks then follow up appt for removal of pessary and insertion of new femring. Pt educated on pessary care and douching and vaginal hygiene. Follow up sooner if problems.
Provider coded as 99213 with primary diagnosis 627.3