twinspana
Contributor
Hello .. I just started a new job and I am auditing E/M levels for a Pediatric urgent care. I have a dilemma
NASAL CONGESTION = can "NASAL" be consider LOCATION and "CONGESTION" the SIGN & SYMPTOMS
the same for CHEST CONGESTION?
I appreciate any assistance ..
EXAMPLE:
Chief Complaint
Nasal congestion
History of Present Illness
Nasal congestion: 11 days old male baby comes in with nasal congestion, chest congestion and wheezing for 3 days, no fever, feeding well. Urinating and stooling normally. Denies sick contacts. no cough or eye discharge.
Birth History: 41 weeks born by c-section for failure to progress, ROM 7-8 hrs, received antibiotics in labor.
Breast fed with formula supplement(similac advance).
NASAL CONGESTION = can "NASAL" be consider LOCATION and "CONGESTION" the SIGN & SYMPTOMS
the same for CHEST CONGESTION?
I appreciate any assistance ..
EXAMPLE:
Chief Complaint
Nasal congestion
History of Present Illness
Nasal congestion: 11 days old male baby comes in with nasal congestion, chest congestion and wheezing for 3 days, no fever, feeding well. Urinating and stooling normally. Denies sick contacts. no cough or eye discharge.
Birth History: 41 weeks born by c-section for failure to progress, ROM 7-8 hrs, received antibiotics in labor.
Breast fed with formula supplement(similac advance).