Can anyone offer advice on this note? I am coming up with a 214 but it seems like the provider had quite the extensive visit with the patient and has chosen a 215 for this.
Patient came to office for an office visit.
Nursing Staff:
Patient assisted by. Previsit Planning completed by xxxx
Vital Signs:
Time: 08:55 AM
Weight: 153 lbs 6 oz
Height: 66"
BMI: 24.74
Temperature: 97.8 F (Oral)
Waist Circumference: 40 inches
BP: 120/72(Right Arm)(Sitting)
Pulse: 44(Left radial)(Sitting)(Regular)
Respiration: 18
Oxygen: 97(Room air)
Chief Complaint:
Ms. xxxx is here for medication refill on all meds. Patient must have paper script to get medications on base.
CHIEF COMPLAINT: Patient states she is here for a chief complaint of redness to right eye.
Patient due for mammogram and bone mass density testing. .
Current Medication:
1 Ranitidine 150 Mg Capsule Take 1 twice daily
2 Aspirin 325 Mg Tablet Take 1 twice daily
3 Levothyroxine 88 Mcg Tablet Take 1 daily
4 Lisinopril 40 Mg Tablet Take 1 daily
5 Ursodiol 300 Mg Capsule Take 2 twice a day
6 Flexeril 5 Mg Tablet Take 1/2 at night for muscle relaxant
7 Flonase 0.05% Nasal Spray 50 Mcg/actuation Instill 2 sprays into each nostril daily
8 Saline Flush 0.9% Syringe Instrill 2 sprays into each nostril daily
9 Boniva 150 Mg Tablet Take 1 tablet every month
10 Fish Oil 1,200 Mg Softgel 360-1,200 Take 1 daily 3/13/13 Patient no longer takes this. to
11 Calcium 600 Mg Tablet Mg (1,500 Mg) (OTC) Take 1 twice daily
12 Glucosamine Complex Caplet 200-300 Mg (OTC) Take 1 twice daily
13 Multivitamin Tablet (OTC) Take 1 daily
14 Vitamin D3 1,000 Unit Tab (OTC) Take 1 daily
15 Cod Liver Oil Softgel (OTC) Take 1 by mouth daily
16 Aspirin 81 Mg Tablet (OTC) take one daily for stroke prevention decrease to 81 mg daily
Allergy/Adverse Reaction:
Hexachlorophene, Hexachlorophene Analogues
Social History:
Social history was reviewed & updated on Mar 13, 2013 by xxxx
Patient has no restrictions to her diet.
Patient has never smoked or used tobacco products.
She denies alcohol use.
She denies recreational drug use.
Patient is married.
Patient lives with her spouse.
Patient is participating in routine exercise.
Patient denies consuming caffeinated drinks.
The patient has not been exposed to any environmental factors which may affect her medical condition.
Patient has no recent travel. She denies exposure to 2nd hand smoke.
Family History:
Family history reviewed and unchanged on Feb 8, 2012 by xxxx, . Patient's father is deceased. He suffered from coronary artery disease and PVD. Patient's mother is deceased. She suffered from coronary artery disease and diabetes type 2.
Patient has 2 brothers. Her first brother is younger than her. He has diabetes type 2. Her second brother is younger than her. He has diabetes type 2.
Patient has one sister. younger. Her sister is living. Has diabetes type 2.
Medical History:
Reviewed and unchanged on Mar 13, 2013: allergies, immunizations, by xxxx Reviewed & updated on Mar 13, 2013: current medication list, medical history, by xxxx.
She has not been hospitalized or visited the ER in the last 12 months.
Specialist(s) seen: Gastroenterology: Dr. xxx Orthopaedic Surgery: Dr. xxxx.
Medical records requested on Mar 13, 2013.
Collaborative Tracking: .
Preventative Screenings: Has had an preventative eye exam on Jan 2013. Patient has not had a preventative dental exam in the last year..
Hypertension. Diagnosed at the age of 55. Treated with medications. Compliance with treatment was good.
Primary Bilary Cirrhosis of the liver dx in 1999.
Allergies:
Hypothyroidism. Diagnosed at the age of 33. The condition was treated with medications. Patient has been compliant with treatment.
Surgeries- Procedures:
Appendectomy 1955,.
Caesarean section 1977,.
Cholecystectomy 2010.,.
Hysterectomy in 1979.
Ob/Gyn History:
OBGYN history was reviewed & updated on Mar 13, 2013 by xxxx.
OBGYN records requested on Mar 13, 2013.
Menarche at age 15.
Gravida 5 para 4 .
xxxx not currently pregnant.
xxxx is not breastfeeding.
Hx of Gyn DX: Significant gynecologic illness(es) the patient had include cervical dysplasia.
No history of STI exposure or disease.
Her sexual partner has no history of STI exposure or disease.
Patient has had no previous gynecologic surgeries.
Last Pap Dec 22, 2011, Findings: negative.
Immunization:
(1) Tdap-age 7+ VFC (Adult)
Location: Left Arm Type: IM Expire Date: 06/27/2015
Manufacturer: Sanofi Pasteur Inc Dose: .5 ml Lot No.: c4366aa
HPI:
HENT:
Patient is here for follow up of allergic rhinitis. Condition is well controlled with treatment regimen. She is currently asymptomatic. Breast-Axilla: Patient denies any breast mass, mastodynia, nipple discharge, nipple retraction, skin changes on the breasts, or mass in the axillary areas. Cardiovascular: xxxx is here for evaluation of hypertension. Patient has Stage I hypertension. Major risk factors for hypertension are present: Dyslipidemia, Female Over 65 years Hypertension is under control. Lifestyle Modification includes: physical activity. Gastrointestinal:
Patient is here for follow up of acid reflux. Condition is well controlled with treatment regimen. She is currently asymptomatic.
here for biliary cirrhosis f/u. See gastroenterologist (Dr Burn at lake regional) in may Musculoskeletal:
Patient is here for follow up of osteoporosis. Condition is well controlled with treatment regimen. She is currently asymptomatic. Endocrine:
Patient is here for follow up of hypothyroid. At present, patient reports fatigue, palpitations and weakness but not lower extremity edema, nausea, restlessness and shortness of breath. Current treatment: levothyroxine takes this first thing in the morning an hour before food. Patient claims good compliance with her medication(s).
ROS:
Current medications reviewed. xxxx claims she is compliant with medications and has experienced no side effects. Past medical history, family history, and social history reviewed.
Examination:
General: The patient is alert and active. She appears well groomed and in no acute distress. Vital signs noted.
Skin: Gross inspection of skin reveals no rash or lesions. Skin is warm and dry.
Lymphatic: No lymph node enlargement or tenderness noted. There is no evidence of acute or chronic lymphedema.
Neck: Supple. No thyromegaly or nodules. No lymphadenopathy.
Breasts & Axilla: Clinical Breast Exam: CBE within normal limits.
Breasts are without significant asymetry, tenderness, palpable masses, skin dimpling, nipple discharge or retraction. No axillary lymphadenopathy is noted.
Respiratory: Lungs are clear to auscultation. No wheezes, rales, or rhonchi noted. Respirations are equal and unlabored.
Cardiovascular: Heart rate is regular. S1 and S2 present with no audible murmurs noted. PMI is non displaced. Peripheral pulses intact, 2+ bil. No pedal edema noted.
Musculoskeletal: There is no evidence of joint pain, tenderness or deformity. Full Range of motion intact to all major joints.
Neurologic: Alert and oriented X 3. Cranial nerves II-XII are grossly intact.
Psychiatric: Appropriately dressed. Does not appear anxious or withdrawn. Speech and affect are appropriate.
MMSE/PHQ/SBIRT:
PHQ:
PHQ2 - 13 & Older-If Yes to Either, Go to PHQ9: PHQ2: Over the last 2 weeks, how often have you been bothered by any of the following problems?.
Feeling Down, Depressed, or Hopeless? No.
Little Interest or Pleasure in Doing Things? No.
Diagnosis:
V76.10 Breast Exam V76.51 Screen malig neop-colon V06.1 DTaP,Tdap (Prophylactic Vaccination and Inoculation Against Diphtheria-Tetanus-Pertussis) 401.9 Hypertension nos 244.9 Hypothyroidism Not Otherwise Specified 477.9 Allergic Rhinitis Not Otherwise Specified 733.00 Osteoporosis Not Otherwise Specified
Diagnostic/Lab:
Diagnostic of your choice
Mammogram - Screening
Diagnostic of your choice
DEXA SCANTSH; CMP; vitamin D
Screening occult
Prescription:
1Mobic 7.5 Mg Tablet SIG: Take one daily for arthritic pain QTY: 90.00 REF: 1
2Ranitidine 150 Mg Capsule SIG: take 1 daily for heart burn QTY: 90.00 REF: 1
Refill Added:
(1) Levothyroxine 88 Mcg Tablet 1 time(s)
(2) Lisinopril 40 Mg Tablet 1 time(s)
(3) Ursodiol 300 Mg Capsule 1 time(s)
(4) Flonase 0.05% Nasal Spray 50 Mcg/actuation 1 time(s)
Changed/Discontinued Medication(s):
Changed: ASPIRIN 325 MG TABLET - decrease to 81 mg daily
Changed: BONIVA 150 MG TABLET
Discontinued: BONIVA 150 MG TABLET - has been on this for more than 5 years.
Discontinued: FISH OIL 1,200 MG SOFTGEL 360-1,200
Changed: FISH OIL 1,200 MG SOFTGEL 360-1,200 - 3/13/13 Patient no longer takes this. to
Discontinued: FLEXERIL 5 MG TABLET
Changed: RANITIDINE 150 MG CAPSULE
Care Plan:
Patient Education/Counseling:
xxxx was assessed for her readiness to make changes in lifestyle for disease prevention and/or long-term disease management.
Does patient eat at least 2-1/2 cups of fruits and vegetables each day? Patient eats fruits and vegetables and has been for less than six (6) months (Action Stage).
Has patient quit smoking/never smoked? Patient has never smoked.
Is patient physically active for 30 or more minutes for 5-7 days a week?Patient is physically active and has been for less than six (6) months (Action Stage).
Status: stable.
Medications: Continue all current medications Discontinue these medications: boniva.
FOLLOW-UP: 6 month(s). Return sooner if the condition changes, worsens, or does not resolve. All questions were addressed. Patient/caretaker appears to clearly understand and is comfortable with careplan. Discussed treatment plan and expected course..
REFUSAL: xxxx declines Tdap today as they state they have had immunizations but do not have documentation. She was encouraged to find documentation and bring it in for inclusion in their record.
CETAPHIL OTC for eye
This visit note has been electronically signed off by following providers.
This visit note has been electronically signed off by xxxx FNP on 03/13/2013 at 12:39 PM.
Patient came to office for an office visit.
Nursing Staff:
Patient assisted by. Previsit Planning completed by xxxx
Vital Signs:
Time: 08:55 AM
Weight: 153 lbs 6 oz
Height: 66"
BMI: 24.74
Temperature: 97.8 F (Oral)
Waist Circumference: 40 inches
BP: 120/72(Right Arm)(Sitting)
Pulse: 44(Left radial)(Sitting)(Regular)
Respiration: 18
Oxygen: 97(Room air)
Chief Complaint:
Ms. xxxx is here for medication refill on all meds. Patient must have paper script to get medications on base.
CHIEF COMPLAINT: Patient states she is here for a chief complaint of redness to right eye.
Patient due for mammogram and bone mass density testing. .
Current Medication:
1 Ranitidine 150 Mg Capsule Take 1 twice daily
2 Aspirin 325 Mg Tablet Take 1 twice daily
3 Levothyroxine 88 Mcg Tablet Take 1 daily
4 Lisinopril 40 Mg Tablet Take 1 daily
5 Ursodiol 300 Mg Capsule Take 2 twice a day
6 Flexeril 5 Mg Tablet Take 1/2 at night for muscle relaxant
7 Flonase 0.05% Nasal Spray 50 Mcg/actuation Instill 2 sprays into each nostril daily
8 Saline Flush 0.9% Syringe Instrill 2 sprays into each nostril daily
9 Boniva 150 Mg Tablet Take 1 tablet every month
10 Fish Oil 1,200 Mg Softgel 360-1,200 Take 1 daily 3/13/13 Patient no longer takes this. to
11 Calcium 600 Mg Tablet Mg (1,500 Mg) (OTC) Take 1 twice daily
12 Glucosamine Complex Caplet 200-300 Mg (OTC) Take 1 twice daily
13 Multivitamin Tablet (OTC) Take 1 daily
14 Vitamin D3 1,000 Unit Tab (OTC) Take 1 daily
15 Cod Liver Oil Softgel (OTC) Take 1 by mouth daily
16 Aspirin 81 Mg Tablet (OTC) take one daily for stroke prevention decrease to 81 mg daily
Allergy/Adverse Reaction:
Hexachlorophene, Hexachlorophene Analogues
Social History:
Social history was reviewed & updated on Mar 13, 2013 by xxxx
Patient has no restrictions to her diet.
Patient has never smoked or used tobacco products.
She denies alcohol use.
She denies recreational drug use.
Patient is married.
Patient lives with her spouse.
Patient is participating in routine exercise.
Patient denies consuming caffeinated drinks.
The patient has not been exposed to any environmental factors which may affect her medical condition.
Patient has no recent travel. She denies exposure to 2nd hand smoke.
Family History:
Family history reviewed and unchanged on Feb 8, 2012 by xxxx, . Patient's father is deceased. He suffered from coronary artery disease and PVD. Patient's mother is deceased. She suffered from coronary artery disease and diabetes type 2.
Patient has 2 brothers. Her first brother is younger than her. He has diabetes type 2. Her second brother is younger than her. He has diabetes type 2.
Patient has one sister. younger. Her sister is living. Has diabetes type 2.
Medical History:
Reviewed and unchanged on Mar 13, 2013: allergies, immunizations, by xxxx Reviewed & updated on Mar 13, 2013: current medication list, medical history, by xxxx.
She has not been hospitalized or visited the ER in the last 12 months.
Specialist(s) seen: Gastroenterology: Dr. xxx Orthopaedic Surgery: Dr. xxxx.
Medical records requested on Mar 13, 2013.
Collaborative Tracking: .
Preventative Screenings: Has had an preventative eye exam on Jan 2013. Patient has not had a preventative dental exam in the last year..
Hypertension. Diagnosed at the age of 55. Treated with medications. Compliance with treatment was good.
Primary Bilary Cirrhosis of the liver dx in 1999.
Allergies:
Hypothyroidism. Diagnosed at the age of 33. The condition was treated with medications. Patient has been compliant with treatment.
Surgeries- Procedures:
Appendectomy 1955,.
Caesarean section 1977,.
Cholecystectomy 2010.,.
Hysterectomy in 1979.
Ob/Gyn History:
OBGYN history was reviewed & updated on Mar 13, 2013 by xxxx.
OBGYN records requested on Mar 13, 2013.
Menarche at age 15.
Gravida 5 para 4 .
xxxx not currently pregnant.
xxxx is not breastfeeding.
Hx of Gyn DX: Significant gynecologic illness(es) the patient had include cervical dysplasia.
No history of STI exposure or disease.
Her sexual partner has no history of STI exposure or disease.
Patient has had no previous gynecologic surgeries.
Last Pap Dec 22, 2011, Findings: negative.
Immunization:
(1) Tdap-age 7+ VFC (Adult)
Location: Left Arm Type: IM Expire Date: 06/27/2015
Manufacturer: Sanofi Pasteur Inc Dose: .5 ml Lot No.: c4366aa
HPI:
HENT:
Patient is here for follow up of allergic rhinitis. Condition is well controlled with treatment regimen. She is currently asymptomatic. Breast-Axilla: Patient denies any breast mass, mastodynia, nipple discharge, nipple retraction, skin changes on the breasts, or mass in the axillary areas. Cardiovascular: xxxx is here for evaluation of hypertension. Patient has Stage I hypertension. Major risk factors for hypertension are present: Dyslipidemia, Female Over 65 years Hypertension is under control. Lifestyle Modification includes: physical activity. Gastrointestinal:
Patient is here for follow up of acid reflux. Condition is well controlled with treatment regimen. She is currently asymptomatic.
here for biliary cirrhosis f/u. See gastroenterologist (Dr Burn at lake regional) in may Musculoskeletal:
Patient is here for follow up of osteoporosis. Condition is well controlled with treatment regimen. She is currently asymptomatic. Endocrine:
Patient is here for follow up of hypothyroid. At present, patient reports fatigue, palpitations and weakness but not lower extremity edema, nausea, restlessness and shortness of breath. Current treatment: levothyroxine takes this first thing in the morning an hour before food. Patient claims good compliance with her medication(s).
ROS:
Current medications reviewed. xxxx claims she is compliant with medications and has experienced no side effects. Past medical history, family history, and social history reviewed.
Examination:
General: The patient is alert and active. She appears well groomed and in no acute distress. Vital signs noted.
Skin: Gross inspection of skin reveals no rash or lesions. Skin is warm and dry.
Lymphatic: No lymph node enlargement or tenderness noted. There is no evidence of acute or chronic lymphedema.
Neck: Supple. No thyromegaly or nodules. No lymphadenopathy.
Breasts & Axilla: Clinical Breast Exam: CBE within normal limits.
Breasts are without significant asymetry, tenderness, palpable masses, skin dimpling, nipple discharge or retraction. No axillary lymphadenopathy is noted.
Respiratory: Lungs are clear to auscultation. No wheezes, rales, or rhonchi noted. Respirations are equal and unlabored.
Cardiovascular: Heart rate is regular. S1 and S2 present with no audible murmurs noted. PMI is non displaced. Peripheral pulses intact, 2+ bil. No pedal edema noted.
Musculoskeletal: There is no evidence of joint pain, tenderness or deformity. Full Range of motion intact to all major joints.
Neurologic: Alert and oriented X 3. Cranial nerves II-XII are grossly intact.
Psychiatric: Appropriately dressed. Does not appear anxious or withdrawn. Speech and affect are appropriate.
MMSE/PHQ/SBIRT:
PHQ:
PHQ2 - 13 & Older-If Yes to Either, Go to PHQ9: PHQ2: Over the last 2 weeks, how often have you been bothered by any of the following problems?.
Feeling Down, Depressed, or Hopeless? No.
Little Interest or Pleasure in Doing Things? No.
Diagnosis:
V76.10 Breast Exam V76.51 Screen malig neop-colon V06.1 DTaP,Tdap (Prophylactic Vaccination and Inoculation Against Diphtheria-Tetanus-Pertussis) 401.9 Hypertension nos 244.9 Hypothyroidism Not Otherwise Specified 477.9 Allergic Rhinitis Not Otherwise Specified 733.00 Osteoporosis Not Otherwise Specified
Diagnostic/Lab:
Diagnostic of your choice
Mammogram - Screening
Diagnostic of your choice
DEXA SCANTSH; CMP; vitamin D
Screening occult
Prescription:
1Mobic 7.5 Mg Tablet SIG: Take one daily for arthritic pain QTY: 90.00 REF: 1
2Ranitidine 150 Mg Capsule SIG: take 1 daily for heart burn QTY: 90.00 REF: 1
Refill Added:
(1) Levothyroxine 88 Mcg Tablet 1 time(s)
(2) Lisinopril 40 Mg Tablet 1 time(s)
(3) Ursodiol 300 Mg Capsule 1 time(s)
(4) Flonase 0.05% Nasal Spray 50 Mcg/actuation 1 time(s)
Changed/Discontinued Medication(s):
Changed: ASPIRIN 325 MG TABLET - decrease to 81 mg daily
Changed: BONIVA 150 MG TABLET
Discontinued: BONIVA 150 MG TABLET - has been on this for more than 5 years.
Discontinued: FISH OIL 1,200 MG SOFTGEL 360-1,200
Changed: FISH OIL 1,200 MG SOFTGEL 360-1,200 - 3/13/13 Patient no longer takes this. to
Discontinued: FLEXERIL 5 MG TABLET
Changed: RANITIDINE 150 MG CAPSULE
Care Plan:
Patient Education/Counseling:
xxxx was assessed for her readiness to make changes in lifestyle for disease prevention and/or long-term disease management.
Does patient eat at least 2-1/2 cups of fruits and vegetables each day? Patient eats fruits and vegetables and has been for less than six (6) months (Action Stage).
Has patient quit smoking/never smoked? Patient has never smoked.
Is patient physically active for 30 or more minutes for 5-7 days a week?Patient is physically active and has been for less than six (6) months (Action Stage).
Status: stable.
Medications: Continue all current medications Discontinue these medications: boniva.
FOLLOW-UP: 6 month(s). Return sooner if the condition changes, worsens, or does not resolve. All questions were addressed. Patient/caretaker appears to clearly understand and is comfortable with careplan. Discussed treatment plan and expected course..
REFUSAL: xxxx declines Tdap today as they state they have had immunizations but do not have documentation. She was encouraged to find documentation and bring it in for inclusion in their record.
CETAPHIL OTC for eye
This visit note has been electronically signed off by following providers.
This visit note has been electronically signed off by xxxx FNP on 03/13/2013 at 12:39 PM.
