Wiki Please help code this History section

Create Wiki
B

benaxixon

Guest
Messages
23
Location
Garden Grove, CA
Best answers
0
Hi,
I'm not sure how to code or give points for this for the "history" section. How would you code this?


CC: Discuss MRI result.
Patient here to discuss MRI results, hx of scalp pain as described in prior visit. Additional info., pt states has been sleeping on left side for years, has hx of right kidney "cyst" which was painful to sleep on, so went to left side.

This is what I gave points on,
HPI: location and modifying factors.
ROS: GI and the integumentary

Did I miss anything? Thanks
 
Location for what? We have no idea what the MRI was even for so this information is all just past history in my opinion. I see no HPI or ROS.

Laura, CPC, CPMA, CEMC
 
I agree with LLovett, what was the MRI for, did it have anything to do with the scalp or the kidney? What is your location, scalp or kidney? What is your modifying factor, sleeping on left side? And how does this relate to the MRI?

All I see is past history, hx of scalp pain, hx of kidney "cyst".
 
Thank you for helping me recognized that. I would give the location for the kidney cyst, but that would fall under the past history already. Can the "so went to the left side." be modifying factor? Thank you.
 
case 2

Patient presents with f/u.


labs d/w pt: CMP FBS 155, GRF 84, UA1+ leuk, wbc 6-10, UCx >100k enterococcus sensitive to amp and vanco, A1C 11.8 (was >14 during hospital admit), CBC H/H 15.7/46.6, FLP Tri 187, TC 231, LDL 143, TSH/urine microalbumn wnl. Saw endo Dr. G and went to DM center and had DM education included use of lantus FBS this morning 160, denies CP/SOB/neuropathy, denies dysuria/freg/urgency recent admit for renal colic, Left kidney stone, Left hydronephrosis, pain meds. given seen by Uro. physician and will f/u with him outpatient to consider surgical removal of stone if it does not pass. Has been taking atorvastatin since given during hospitalization. Can do better with hydrating with water.

**I was able to get severity and modifying factors and associated signs and symptoms.
ROS: CARDIO, RESP, GU, AND ENDO
 
You must log in or register to reply here.
Top