Elund
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The documentation:
Why aren't the external cause codes reported here?
Why isn't the 80 mg propofol (Diprivan) injection reported?
And why isn't the X-ray reported? There's no mention of it being provided by anyone other than the reporting physician.
MEDICAL RECORD
EMERGENCY DEPARTMENT
Age 26
Sex: M
DOS: 1/1/20XX
CHIEF COMPLAINT: Left ankle pain.
HPI: This is a male who was playing football when another player landed on his left ankle and he fell to the ground. He heard a pop and saw his leg deformed. He denies any other injuries and was wearing a helmet. He otherwise feels well. He comes in with a splint on his leg, but no pain medication prior to arrival.
PAST MEDICAL HISTORY: Denies.
MEDICATIONS: Denies.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient does not smoke or drink alcohol.
REVIEW OF SYSTEMS: As per the HPI, otherwise unremarkable. He specifically also does not have any distal paresthesias, though he does have some numbness about the ankle.
PHYSICAL EXAM: VITAL SIGNS: Temperature 99.4, pulse 76, respiratory rate 16, pulse oximetry 100%, blood pressure 126/75.
GENERAL: He is a well-developed, well-nourished, pleasant young man appearing his stated age and appearing to be in a good bit of pain.
HEENT: Pupils are equal, round and reactive to light. Oropharynx, clear.
NECK: No vertebral tenderness. RESPIRATORY: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or rubs. GI: Soft, nontender, nondistended with normal bowel sounds.
EXTREMITIES: The patient's left leg is in a splint. You can see that there is notable deformity. Capillary refill distally is intact and less than 2. NEURO: Distal sensation and motion are intact.
EMERGENCY ROOM COURSE: X-ray reveals a bimalleolar fracture with a posterior and lateral malleolus fracture as well as dislocation of the ankle.
I discussed the findings with the patient and the need for conscious sedation as well as manipulation and need for ultimate surgery. Discussion occurred before pain medications were received by the patient. Risks and benefits of sedation with Diprivan were discussed. The patient agreed to proceed with sedation.
Conscious Sedation: Intraservice time - 20 minutes
I personally administered Diprivan 80 mg IV.
Respiratory Therapy was at the head of the bed and did assist with bag valve mask briefly during the procedure. The patient never was hypoxic. I manually did closed reduction and was completed of the left ankle and a 3-sided plaster splint applied. The patient tolerated this well and woke up at the end of the procedure after splinting was completed. He remains distally neurovascularly intact after splint was applied by me.
I spoke with Orthopedic physician who wishes to do surgery tomorrow. The patient does not want to stay in the hospital overnight, so is being released home. Prescription was given for Vicodin. The patient is to return at 10 a.m. Return precautions are given.
DIAGNOSIS: 1. Left ankle fracture and dislocation. 2. Status post closed reduction with procedural sedation.
DISPOSITION: Home in improved condition with plan to return for surgery in a few hours.
Clarence Kramer, MD - Electronically signed by CLARENCE KRAMER, MD 1/1/20XX
EMERGENCY DEPARTMENT
Age 26
Sex: M
DOS: 1/1/20XX
CHIEF COMPLAINT: Left ankle pain.
HPI: This is a male who was playing football when another player landed on his left ankle and he fell to the ground. He heard a pop and saw his leg deformed. He denies any other injuries and was wearing a helmet. He otherwise feels well. He comes in with a splint on his leg, but no pain medication prior to arrival.
PAST MEDICAL HISTORY: Denies.
MEDICATIONS: Denies.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient does not smoke or drink alcohol.
REVIEW OF SYSTEMS: As per the HPI, otherwise unremarkable. He specifically also does not have any distal paresthesias, though he does have some numbness about the ankle.
PHYSICAL EXAM: VITAL SIGNS: Temperature 99.4, pulse 76, respiratory rate 16, pulse oximetry 100%, blood pressure 126/75.
GENERAL: He is a well-developed, well-nourished, pleasant young man appearing his stated age and appearing to be in a good bit of pain.
HEENT: Pupils are equal, round and reactive to light. Oropharynx, clear.
NECK: No vertebral tenderness. RESPIRATORY: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or rubs. GI: Soft, nontender, nondistended with normal bowel sounds.
EXTREMITIES: The patient's left leg is in a splint. You can see that there is notable deformity. Capillary refill distally is intact and less than 2. NEURO: Distal sensation and motion are intact.
EMERGENCY ROOM COURSE: X-ray reveals a bimalleolar fracture with a posterior and lateral malleolus fracture as well as dislocation of the ankle.
I discussed the findings with the patient and the need for conscious sedation as well as manipulation and need for ultimate surgery. Discussion occurred before pain medications were received by the patient. Risks and benefits of sedation with Diprivan were discussed. The patient agreed to proceed with sedation.
Conscious Sedation: Intraservice time - 20 minutes
I personally administered Diprivan 80 mg IV.
Respiratory Therapy was at the head of the bed and did assist with bag valve mask briefly during the procedure. The patient never was hypoxic. I manually did closed reduction and was completed of the left ankle and a 3-sided plaster splint applied. The patient tolerated this well and woke up at the end of the procedure after splinting was completed. He remains distally neurovascularly intact after splint was applied by me.
I spoke with Orthopedic physician who wishes to do surgery tomorrow. The patient does not want to stay in the hospital overnight, so is being released home. Prescription was given for Vicodin. The patient is to return at 10 a.m. Return precautions are given.
DIAGNOSIS: 1. Left ankle fracture and dislocation. 2. Status post closed reduction with procedural sedation.
DISPOSITION: Home in improved condition with plan to return for surgery in a few hours.
Clarence Kramer, MD - Electronically signed by CLARENCE KRAMER, MD 1/1/20XX
Why aren't the external cause codes reported here?
Why isn't the 80 mg propofol (Diprivan) injection reported?
And why isn't the X-ray reported? There's no mention of it being provided by anyone other than the reporting physician.