Hello,
This is the ov note and note sure what to use for the aftercare codes. Any help would be great. Thank you
HISTORY OF PRESENT ILLNESS: --- is now two weeks from her right knee arthroscopy, ACL reconstruction using allograft, medial meniscus repair, medial femoral chondroplasty, and patellar chondroplasty, extensor synovectomy. The patient is doing very, very well. Symptoms seemed to be improving. --- is very pleased with her progress. --- is still feeling somewhat fatigued and I talked with --- about this at length. --- has been seeing --- primary care physician and they are thinking there is a possibility of --- having UTI. Otherwise, --- is progressing well with --- knee.
Past medical history, allergies, medications, past surgical history, and social history all reviewed with the patient today; any changes signed and dated.
REVIEW OF SYSTEMS: Denies weight change, fever, chills, lumps, or masses. Denies chest pain, irregular heartbeat, or heart murmurs. Denies shortness of breath, cough, or wheezing.
PHYSICAL EXAMINATION: A very pleasant ---year-old ---, in no acute distress, alert and oriented x3, height and weight are unchanged, and respirations 16. Affect is appropriate during the exam. Right knee with no effusion. Range of motion is 0 to 120 degrees. No joint line pain. No opening with varus or valgus stress. Negative Lachman's, negative anterior drawer, and negative posterior drawer. Calf is soft and nontender. Both lower extremities have no caf?-au-lait spots. No evidence of collagen disorder. Distal pulses intact at 2+. Capillary refill is less than 3 seconds. Right knee, well-healed surgical scars. No signs of infection. Range of motion is 0 to 110 degrees. Solid endpoint on Lachman?s.
RADIOGRAPHS: AP and lateral shows satisfactory position of the bone tunnels and 15-mm EndoButton.
IMPRESSION: Good course.
PLAN: The patient is progressing well through physical therapy. We went through postop pictures with the patient today and talked about postop protocol. We will see --- back in four weeks' time. She will keep in contact with her primary care physician regarding her continued fatigue.
This is the ov note and note sure what to use for the aftercare codes. Any help would be great. Thank you
HISTORY OF PRESENT ILLNESS: --- is now two weeks from her right knee arthroscopy, ACL reconstruction using allograft, medial meniscus repair, medial femoral chondroplasty, and patellar chondroplasty, extensor synovectomy. The patient is doing very, very well. Symptoms seemed to be improving. --- is very pleased with her progress. --- is still feeling somewhat fatigued and I talked with --- about this at length. --- has been seeing --- primary care physician and they are thinking there is a possibility of --- having UTI. Otherwise, --- is progressing well with --- knee.
Past medical history, allergies, medications, past surgical history, and social history all reviewed with the patient today; any changes signed and dated.
REVIEW OF SYSTEMS: Denies weight change, fever, chills, lumps, or masses. Denies chest pain, irregular heartbeat, or heart murmurs. Denies shortness of breath, cough, or wheezing.
PHYSICAL EXAMINATION: A very pleasant ---year-old ---, in no acute distress, alert and oriented x3, height and weight are unchanged, and respirations 16. Affect is appropriate during the exam. Right knee with no effusion. Range of motion is 0 to 120 degrees. No joint line pain. No opening with varus or valgus stress. Negative Lachman's, negative anterior drawer, and negative posterior drawer. Calf is soft and nontender. Both lower extremities have no caf?-au-lait spots. No evidence of collagen disorder. Distal pulses intact at 2+. Capillary refill is less than 3 seconds. Right knee, well-healed surgical scars. No signs of infection. Range of motion is 0 to 110 degrees. Solid endpoint on Lachman?s.
RADIOGRAPHS: AP and lateral shows satisfactory position of the bone tunnels and 15-mm EndoButton.
IMPRESSION: Good course.
PLAN: The patient is progressing well through physical therapy. We went through postop pictures with the patient today and talked about postop protocol. We will see --- back in four weeks' time. She will keep in contact with her primary care physician regarding her continued fatigue.
