Bernadette10
Guru
Would this be level 2 or 3?
HPI: The patient is 1 week post RT elbow injury. He was seen in the ER one week ago and had x-rays reviewed by Dr. X, who noted no obvious fractures at that time. However, he had significant pain and swelling and was placed in a posterior splint and is here for followup.
Exam: He has diffuse tenderness about the RT arm but most especially over the elbow and lateral elbow. Intact supination and pronation about the forearm, although this causes elbow pain. Intact sensation of the RT hand radial, ulnar and median.
Assessment/Plan: RT elbow injury. His arm is clean, and given his pain and discomfort with flexion and extension, he is re-splinted in a well-padded posterior fiberglass splint, and we will see him back in a week with new x-rays out of the splint.
My thoughts are level 3.
Problem complexity is low for an acute, uncomplicated injury. Or is it straightforward for a self-limited, minor problem? I'm thinking low since they're not completely sure what the injury is, or at least this isn't stated.
Data is straightforward for 1 future x-ray ordered.
Risk is low for the splint placement. Or is a splint straightforward MDM? (This provider is not good at adding procedure notes or answering queries, and we were told to just not bill them if there isn't a procedure note, so I don't know if this was a pre-made splint or made by the provider).
HPI: The patient is 1 week post RT elbow injury. He was seen in the ER one week ago and had x-rays reviewed by Dr. X, who noted no obvious fractures at that time. However, he had significant pain and swelling and was placed in a posterior splint and is here for followup.
Exam: He has diffuse tenderness about the RT arm but most especially over the elbow and lateral elbow. Intact supination and pronation about the forearm, although this causes elbow pain. Intact sensation of the RT hand radial, ulnar and median.
Assessment/Plan: RT elbow injury. His arm is clean, and given his pain and discomfort with flexion and extension, he is re-splinted in a well-padded posterior fiberglass splint, and we will see him back in a week with new x-rays out of the splint.
My thoughts are level 3.
Problem complexity is low for an acute, uncomplicated injury. Or is it straightforward for a self-limited, minor problem? I'm thinking low since they're not completely sure what the injury is, or at least this isn't stated.
Data is straightforward for 1 future x-ray ordered.
Risk is low for the splint placement. Or is a splint straightforward MDM? (This provider is not good at adding procedure notes or answering queries, and we were told to just not bill them if there isn't a procedure note, so I don't know if this was a pre-made splint or made by the provider).