arkolab
New
Is it appropriate to count decision regarding an elective major surgery under the risk column when the provider goes over risks and benefits of different treatment options but chooses not to proceed with surgery at this time?
For example:
ASSESSMENT: Degenerative arthritis of proximal interphalangeal joint of little finger of left hand (primary encounter diagnosis)
Chronic wrist pain, left
Mass of wrist, left
Digital mucinous cyst of finger
PLAN: I discussed with patient the diagnosis and my impression, its etiology, and different workup and treatment options, including wrapping and surgical excision, we discussed arthroplasty and injection as well as risks. We discussed different management options and the risks/benefits of each. We discussed expectations and prognosis. We discussed the joint and cyst considerations as well as recurrence. After this detailed discussion, the patient is electing for injection which is performed.
For example:
ASSESSMENT: Degenerative arthritis of proximal interphalangeal joint of little finger of left hand (primary encounter diagnosis)
Chronic wrist pain, left
Mass of wrist, left
Digital mucinous cyst of finger
PLAN: I discussed with patient the diagnosis and my impression, its etiology, and different workup and treatment options, including wrapping and surgical excision, we discussed arthroplasty and injection as well as risks. We discussed different management options and the risks/benefits of each. We discussed expectations and prognosis. We discussed the joint and cyst considerations as well as recurrence. After this detailed discussion, the patient is electing for injection which is performed.