mlemon
Networker
The following is an example of a note that was dicated by our physician. I am curious to see what level this would have been coded as.
Thanks in advance for your feedback....
DIAGNOSIS:
Infiltrating ductal carcinoma of the right breast, T1 (1.4 cm) N0 M0, diagnosed 2001, ER weakly positive, PR positive, grade 3, HER-2/neu not overexpressed. The patient is premenopausal.
TREATMENT RECEIVED:
Adjuvant chemotherapy with EC times 4, followed by Taxotere times 3 (discontinued because of toxicity).
Adjuvant radiation.
The patient decided against hormonal treatment.
SUBJECTIVE:
The patient is seen in annual followup. Clinically, she continues to do well. She denies any specific complaints. Appetite is normal. Her weight has been stable. Her menstrual cycles have been regular every month. No changes in her past medical history, family history, or social history since her last visit. Her 10-system review is essentially unremarkable.
PHYSICAL EXAMINATION:
GENERAL: The patient appears well. VITAL SIGNS: Weight 126 pounds. Afebrile. Pulse 80. Blood pressure 117/76. She is alert, awake, and oriented times 3. HEENT: Pupils equal and reactive. Extraocular movement intact. No pallor or scleral icterus. Oral mucosa is moist. Nasopharynx is benign. NECK: Supple. LYMPH NODE SURVEY: No palpable cervical or supraclavicular lymphadenopathy. LUNGS: Clear to percussion and auscultation bilaterally. HEART: S1 and S2, regular rate and rhythm. No murmurs, rubs, or gallops appreciated. CHEST WALL: Right breast with a well-healed lumpectomy scare in the right upper quadrant. No palpable masses. Left breast is normal with no palpable masses, skin or nipple changes. ABDOMEN: Soft, nontender. No organomegaly. Bowel sounds are normal. EXTREMITIES: No cyanosis, edema, or clubbing. NEUROLOGIC: Grossly nonfocal. MUSCULOSKELETAL: No spinal, paraspinal, or costovertebral tenderness. SKIN: No lesions or bruises.
DIAGNOSTIC STUDIES:
Laboratory
CBC: White cell count 4.9. Hemoglobin 13.5. Hematocrit 40.4. Platelets 198,000.
Imaging
Mammogram done February 2010 revealed benign findings with postlumpectomy changes on the right, otherwise unremarkable. Annual followup has been recommended.
ASSESSMENT:
Premenopausal patient who is seen in annual followup. Clinically, she is doing well. There is no evidence of recurrence clinically or by her recent mammogram.
PLAN:
Annual followup. She has a mammogram scheduled by Dr. Smith. We have talked to her about tumor markers. This is not a standard recommendation. However, we will add these on with her next visit.
Thanks in advance for your feedback....
DIAGNOSIS:
Infiltrating ductal carcinoma of the right breast, T1 (1.4 cm) N0 M0, diagnosed 2001, ER weakly positive, PR positive, grade 3, HER-2/neu not overexpressed. The patient is premenopausal.
TREATMENT RECEIVED:
Adjuvant chemotherapy with EC times 4, followed by Taxotere times 3 (discontinued because of toxicity).
Adjuvant radiation.
The patient decided against hormonal treatment.
SUBJECTIVE:
The patient is seen in annual followup. Clinically, she continues to do well. She denies any specific complaints. Appetite is normal. Her weight has been stable. Her menstrual cycles have been regular every month. No changes in her past medical history, family history, or social history since her last visit. Her 10-system review is essentially unremarkable.
PHYSICAL EXAMINATION:
GENERAL: The patient appears well. VITAL SIGNS: Weight 126 pounds. Afebrile. Pulse 80. Blood pressure 117/76. She is alert, awake, and oriented times 3. HEENT: Pupils equal and reactive. Extraocular movement intact. No pallor or scleral icterus. Oral mucosa is moist. Nasopharynx is benign. NECK: Supple. LYMPH NODE SURVEY: No palpable cervical or supraclavicular lymphadenopathy. LUNGS: Clear to percussion and auscultation bilaterally. HEART: S1 and S2, regular rate and rhythm. No murmurs, rubs, or gallops appreciated. CHEST WALL: Right breast with a well-healed lumpectomy scare in the right upper quadrant. No palpable masses. Left breast is normal with no palpable masses, skin or nipple changes. ABDOMEN: Soft, nontender. No organomegaly. Bowel sounds are normal. EXTREMITIES: No cyanosis, edema, or clubbing. NEUROLOGIC: Grossly nonfocal. MUSCULOSKELETAL: No spinal, paraspinal, or costovertebral tenderness. SKIN: No lesions or bruises.
DIAGNOSTIC STUDIES:
Laboratory
CBC: White cell count 4.9. Hemoglobin 13.5. Hematocrit 40.4. Platelets 198,000.
Imaging
Mammogram done February 2010 revealed benign findings with postlumpectomy changes on the right, otherwise unremarkable. Annual followup has been recommended.
ASSESSMENT:
Premenopausal patient who is seen in annual followup. Clinically, she is doing well. There is no evidence of recurrence clinically or by her recent mammogram.
PLAN:
Annual followup. She has a mammogram scheduled by Dr. Smith. We have talked to her about tumor markers. This is not a standard recommendation. However, we will add these on with her next visit.