noninoniok
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Hi I am new to coding & the clinic I am working at has just received a new provider. He has asked me to codes this out for him & I'm not quite sure where to start? A lot of this doesn't make sense to me as it's not complete sentences & when I asked for more info I was told there is enough to code it out. Can someone help me with this please? I will be forever grateful!! Thanks Loni
Pt presented with Urethral Irritations with Foley x7yrs status post, Prostatectomy/Microwave (Radiation) pt also has herpes and is currently on Symlin Medication.
O2 sat 94%, Pulse 80 bladder is very small fills with 600cc Intramuscular sedation 15mg Ketamine with Intramuscular 2.5mg Versed.
Pt very uncomfortable 75mg more Ketamine introduced in IV. Superpubic, cleaned with Beta Dine x3.
1.5cm introduced in Superpubic with 18 gauge needle. Located urine blood pink with filling of bladder very tight. Used 15in blade to 1cm skin then trocor with Superpubic catheter placed.
Imp: Urethral Irritation with Fissure
Plan: Superpubic catheter placement with anesthesia - conscious O2 Sat > 90% Keflex 500 tid x5 days leave cath in penis until status post draining. Check at 4 weeks.
Pt presented with Urethral Irritations with Foley x7yrs status post, Prostatectomy/Microwave (Radiation) pt also has herpes and is currently on Symlin Medication.
O2 sat 94%, Pulse 80 bladder is very small fills with 600cc Intramuscular sedation 15mg Ketamine with Intramuscular 2.5mg Versed.
Pt very uncomfortable 75mg more Ketamine introduced in IV. Superpubic, cleaned with Beta Dine x3.
1.5cm introduced in Superpubic with 18 gauge needle. Located urine blood pink with filling of bladder very tight. Used 15in blade to 1cm skin then trocor with Superpubic catheter placed.
Imp: Urethral Irritation with Fissure
Plan: Superpubic catheter placement with anesthesia - conscious O2 Sat > 90% Keflex 500 tid x5 days leave cath in penis until status post draining. Check at 4 weeks.
