Hi can someone tell me if I coded this wound care correctly? I never did wound care before
99204
a6260
97597
Assessment
1. Laceration of right middle finger without foreign body without damage to nail, initial
encounter (S61.212A)
Referral to hand specialist to ensure no other interventions are needed. This seems
unlikely as he just has fingertip avulsions. Discussed the importance of wound care and
provided education on how to care for the wounds. Discussed work restrictions and will
let hand surgeon guide this further. Report for concerns of infection immediately.
2. Avulsion of finger tip, initial encounter (S61.209A)
Referral to hand specialist to ensure no other interventions are needed. This seems
unlikely as he just has fingertip avulsions. Discussed the importance of wound care and
provided education on how to care for the wounds. Discussed work restrictions and will
let hand surgeon guide this further. Report for concerns of infection immediately.
3. Visit for wound check (Z51.89)
We will send a referral to a hand specialist for further evaluation.
I will fill out the form and fax it to the patient and the hand specialist.
The patient can return to work on 05/18/2023 with light duty, avoiding lifting and moving
with his right hand.
He should report any concerns about infection immediately.
I used a different dressing because it should be a nonstick, nonadherent dressing.
I educated the patient on different types of nonadherent dressings.
I informed the patient that saline rinses are good.
I recommended that he apply Neosporin ointment twice a day.
Procedure
Procedure:. Dressing change. Risks, benefits, alternatives, risk of pain/discomfort and risk of excessive bleeding were discussed with the patient and parent. Written consent was obtained prior to the procedure and is detailed in the patient's record.
Procedure Note:
Anesthesia:
Wound #1: a laceration, a avulsion tip and Suture placed right middler finger tip is healing. Preparation & Topical Therapy: irrigation.
Vaseline and nonadherent after polysporin applied. dressing was applied. There was minimal bleeding.
Wound #2:
A laceration and avulsion of skin tip Right ring finger is healing. Preparation & Topical Therapy: irrigation.
Vaseline and nonadherent dressing was applied. There was minimal bleeding.
Post-Procedure:
the patient tolerated the procedure well. There were no complications. Antibiotics: no antibiotic was prescribed.
The patient was instructed to call the office if he saw any signs/symptoms of infection (fever, warmth, erythema, localized tenderness, purulent discharge, foul odor, delayed wound healing, etc.), cleanse the wound with soap and water, apply polysporin and apply a dressing 2 time(s) daily. Follow-Up and Referrals: referred to hand surgeon.
Chief Complaint
NP visit, check wound on finger, cut fingers on ceiling fan Sunday night, went to ER and got middle finger stitched and and bandaged
History of Present Illness
presents to the office for an established visit and to check his fingers. The patient is accompanied by 2 adult females.
He denies any major medical history, major illness, hospitalizations, surgeries, or medications.
The incident took place on Sunday, 05/14/2023, while he was clipping the frame and light and cut his fingers off on ceiling fan. He went to the emergency room and got his middle finger stitched and bandaged. He redressed the wound. He denies taking the tetanus vaccine. He does not have much pain. He will follow up with the specialist after 10 days, depending on the status of the wound. His wound should be cleaned after 48 hours and should not be soaked. The accompanied female questions the solution for rinsing the wound, and she also questions whether to wait 7 days to consult a specialist or not. The female companion finds it difficult to clean him up.
He denies having any allergies.
99204
a6260
97597
Assessment
1. Laceration of right middle finger without foreign body without damage to nail, initial
encounter (S61.212A)
Referral to hand specialist to ensure no other interventions are needed. This seems
unlikely as he just has fingertip avulsions. Discussed the importance of wound care and
provided education on how to care for the wounds. Discussed work restrictions and will
let hand surgeon guide this further. Report for concerns of infection immediately.
2. Avulsion of finger tip, initial encounter (S61.209A)
Referral to hand specialist to ensure no other interventions are needed. This seems
unlikely as he just has fingertip avulsions. Discussed the importance of wound care and
provided education on how to care for the wounds. Discussed work restrictions and will
let hand surgeon guide this further. Report for concerns of infection immediately.
3. Visit for wound check (Z51.89)
We will send a referral to a hand specialist for further evaluation.
I will fill out the form and fax it to the patient and the hand specialist.
The patient can return to work on 05/18/2023 with light duty, avoiding lifting and moving
with his right hand.
He should report any concerns about infection immediately.
I used a different dressing because it should be a nonstick, nonadherent dressing.
I educated the patient on different types of nonadherent dressings.
I informed the patient that saline rinses are good.
I recommended that he apply Neosporin ointment twice a day.
Procedure
Procedure:. Dressing change. Risks, benefits, alternatives, risk of pain/discomfort and risk of excessive bleeding were discussed with the patient and parent. Written consent was obtained prior to the procedure and is detailed in the patient's record.
Procedure Note:
Anesthesia:
Wound #1: a laceration, a avulsion tip and Suture placed right middler finger tip is healing. Preparation & Topical Therapy: irrigation.
Vaseline and nonadherent after polysporin applied. dressing was applied. There was minimal bleeding.
Wound #2:
A laceration and avulsion of skin tip Right ring finger is healing. Preparation & Topical Therapy: irrigation.
Vaseline and nonadherent dressing was applied. There was minimal bleeding.
Post-Procedure:
the patient tolerated the procedure well. There were no complications. Antibiotics: no antibiotic was prescribed.
The patient was instructed to call the office if he saw any signs/symptoms of infection (fever, warmth, erythema, localized tenderness, purulent discharge, foul odor, delayed wound healing, etc.), cleanse the wound with soap and water, apply polysporin and apply a dressing 2 time(s) daily. Follow-Up and Referrals: referred to hand surgeon.
Chief Complaint
NP visit, check wound on finger, cut fingers on ceiling fan Sunday night, went to ER and got middle finger stitched and and bandaged
History of Present Illness
presents to the office for an established visit and to check his fingers. The patient is accompanied by 2 adult females.
He denies any major medical history, major illness, hospitalizations, surgeries, or medications.
The incident took place on Sunday, 05/14/2023, while he was clipping the frame and light and cut his fingers off on ceiling fan. He went to the emergency room and got his middle finger stitched and bandaged. He redressed the wound. He denies taking the tetanus vaccine. He does not have much pain. He will follow up with the specialist after 10 days, depending on the status of the wound. His wound should be cleaned after 48 hours and should not be soaked. The accompanied female questions the solution for rinsing the wound, and she also questions whether to wait 7 days to consult a specialist or not. The female companion finds it difficult to clean him up.
He denies having any allergies.