No one in the office here does chart audits so I would greatly appreciate the advice/input from others. For this note I came up with History- Detailed, Exam- PF, MDM-Moderate but I am questioning myself on the level 4.
Can anyone else review this and let me know what you have come up with in auditing this note for the History, Examination, and MDM?
Visit Note - Office Visit
Provider: DO
Encounter Date: Apr 23, 2013
Patient: xxx
Gender: Female DOB: xxx Age: 58 year 2 month
Race: White
Address: xxx
Insurance: xxxx
Patient came to office for an office visit.
Nursing Staff:
Patient assisted by xxx, LPN. Previsit Planning completed by xxxx, LPN.
Vital Signs:
Time: 10:12 AM
Weight: 173 lbs 12 oz
Height: 63"
BMI: 30.77
BSA: 1.87
Temperature: 96.7 F (Tympanic)
Waist Circumference: 39 inches
BP: 134/84(Left Arm)(Sitting)
Pulse: 64(Apical)(Sitting)(Regular)
Respiration: 20
Oxygen: 98(Room air)
Chief Complaint:
Ms. xxx is here for further evaluation of right knee. Patient had a fall. – by XXX,LPN
Current Medication:
1 Lidoderm 5% Patch %(700 Mg/patch) Apply 1 in 12 hors then off for 12 hours
2 Freestyle Freedom Glucometer Kit
3 Freestyle Freedom Test Strips Use 1 strip twice daily as directed
4 Nasonex 50 Mcg Nasal Spray Mcg/actuation Inhale 2 sprays in each nostril once daily
5 Atenolol 50 Mg Tablet Take 1 daily
6 Lancets Use one 3 times daily and as needed
7 Wrist Blood Pressure Cuff Use daily or as directed
8 Loratadine 10 Mg Tablet Take 1 tablet daily as needed for allergies
9 Paroxetine Hcl 30 Mg Tablet Take 1 daily
10 Iron 325 Mg Tablet (65 Mg Iron) Take 1 daily
11 Welchol 625 Mg Tablet 3 TABS TWICE A DAY
12 Torsemide 20 Mg Tablet Take 1 daily
13 Fish Oil 1,200 Mg Softgel 360-1,200 take 1 daily
14 Zantac 300 Mg Tablet Take 1 tablet(s) daily
15 Gabapentin 100 Mg Capsule Take 1 three times a day
16 Lantus 100 Units/ml Vial Unit/ml Take 5 units daily at bedtime
17 Cozaar 50 Mg Tablet 1 daily
18 Reglan 10 Mg Tablet Take 1/2 tab four times daily
19 Amlodipine Besylate 5 Mg Tab 1 daily
20 Calcium,magnesium,zinc 1 AM ON EMPTY STOMACH AND 1 @ HS
21 Methocarbamol 750 Mg Tablet Take as needed
22 Norvasc 5 Mg Tablet Take 1 daily
23 Ropinirole Hcl 2 Mg Tablet Take 1 daily at bedtime
24 Thiamine 100 Mg Tablet 1 po daily
25 Vitamin B12 2,000 Mcg Tab Sa (OTC) Take 1 daily
26 Women's 50+ Advanced Capsule 400 Mcg (OTC) Take 1 daily
27 Lamictal 25 Mg Tablet (Other MD) take 1 tab x2 daily for week1 and 2, then 2 tabs x2 daily for weeks 3 and4, then 3 tabs x 2 daily for weeks 5 and 6, 4 tabs x2 daily for week 7 and onwards
28 Vit D2 1.25 Mg (50,000 Unit) (Dr LARDIZBAL) 1 weekly x 12 doses
29 Protonix Dr 40 Mg Tablet (Other MD) Take 1 twice daily
Allergy/Adverse Reaction:
Adhesive Tape, Iodine, Large dose aspirin, Niacin, Statins, NSAIDS
Social History:
Social history reviewed and unchanged on Apr 23, 2013 by XXX, LPN.
Diet type: low sugar diet.
Debra used to use tobacco products. She quit smoking 1973.
She denies alcohol use.
Pre-SBIRT:Completed on Oct 16, 2012. When was the last time you had 4 standard drinks in a day or night? Was that within the last three months? No. In the last 12 months, did you ever find yourself drinking more than you meant to? No. In the last 12 months, did you smoke pot, use another street drug, or use a prescription painkiller, stimulant, or sedative for a non-medical reason? No.
She denies recreational drug use.
Patient is divorced once.
Patient lives with her 1 granddaughter and 1 grandson.
Patient is participating in routine exercise.
Caffeine intake consists of She denies drinking caffeinated coffee. She denies drinking caffeinated soda., She denies drinking caffeinated tea.
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 Apr 23, 2013 by XXX, LPN. Positive Family History: (+) diabetes type 2, (+) epilepsy, (+) Heart Disease, (+) malignancy (+) brain cancer in a brother, (+) breast cancer, in 2 aunts, (+) cervical cancer, in an aunt, (+) lung cancer, in a brother, (+) stomach cancer, in an aunt and (+) Heart Attack in father, in paternal grandfather.
Medical History:
Reviewed and unchanged on Apr 23, 2013: allergies, current medication list (including problems or difficulties taking the medications were documented as needed), medical history, immunizations, by LPN.
Her last ER visit was on Feb 9, 2013 for Low blood sugar, dehydration, possible seizure, UTI.
Xxx has not seen a specialist since last visit.
Does not see a specialist at this time.
No medical records are needed at this time.
Collaborative Tracking: .
Diabetes: Has had a diabetic eye exam on Aug 2012. Patient has not had a dental exam in the past year. Patient had a diabetic foot exam on Oct 16, 2012. Patient had a HA1C Mar 7, 2013. Patient had a lipid screening Mar 7, 2013. Annual microalbumin testing on Oct 16, 2012. Patient not taking daily aspirin. Most recent flu shot done on Oct 10, 2011. Most recent pneumonia vaccination done on Oct 10, 2011.
Preventative Screenings: Has had an preventative eye exam on 2012. Patient had a preventative dental exam on 2012..
Angina. Date of diagnosis is unknown.
Hypercholesterolemia. Date of diagnosis is unknown. Pt did not tolerate statins and had severe flushing with Niacin (however, she did not take an aspirin with it).
Hypertension. Date of diagnosis is unknown.
Gastroesophageal reflux. Date of diagnosis is unknown.
Irritable bowel syndrome. Date of diagnosis is unknown.
Peptic ulcer disease. Date of diagnosis is unknown.
Back pain. Date of diagnosis is unknown.
Carpal tunnel syndrome. Date of diagnosis is unknown.
Lumbar disc disease. Date of diagnosis is unknown.
Restless legs syndrome. Date of diagnosis is unknown.
Patient has appt. for EEG AND MR 1-30-12.
Obesity. Date of diagnosis is unknown.
Cushing's disease. Date of diagnosis is unknown.
Type 2 diabetes. Date of diagnosis is unknown.
Arthritis. Date of diagnosis is unknown.
Fibromyalgia. Date of diagnosis is unknown.
Surgeries- Procedures:
COLONOSCOPY: Colonoscopy 2005,.
Gallbladder surgery Dec 2012,.
Hysterectomy in 1992 (abdominal , complete, due to bleeding.).,.
Tonsillectomy, Back: She had discectomies and/or laminectomies on all 5 lumbar vertebrae in 2003.
Right rotator cuff repair in 1990.
Heart cath.
.
Ob/Gyn History:
OBGYN history was reviewed & updated on Mar 14, 2013 by XXX, LPN.
Date of LMP:1992.
Gravida 5 para 3 .
xxx not currently pregnant.
xxx is not breastfeeding.
Hx of Gyn DX: Significant gynecologic illness(es) the patient had include endometriosis.
No history of STI exposure or disease.
Procedures: tubal ligation done on 1980.
She had a mammogram on Nov 16, 2011 which showed normal result (ultral sound recommened due to lump felt on left breast).
Performs self breast exam. Montlhy.
Patient is not sexually active. Last Pap--1995.
HPI:
58 year 2 month age old patient is here for patient fell 3 and 1/2 weeks ago and she has right knee pain and pain radiating up her right leg. She fell up some steps. She denies unconciousness. Patient did not go to the ER. Respiratory: She denies shortness of breath, cough, pain with deep breath, wheezing or any other complaints related to respiratory system. Cardiovascular: She denies chest pain, palpitations, fainting spells, pedal edema or shortness of breath. Genitourinary: No complaints of pain with urination, frequency, urgency or hematuria.
PHQ reviewed.No follow-up or treatment needed at this time.
ROS:
See HPI.
Current medications reviewed. XXX claims she is compliant with medications and has experienced no side effects. Past medical history, family history, and social history reviewed.
Examination:
Musculoskeletal:
KNEE: Inspection of the right knee joint reveals no deformity, swelling, quadriceps atrophy, asymmetry or misalignment. Range of motion is restricted with internal rotation and external rotation. No pain is noted during flexion, extension, internal rotation, external rotation, adduction and abduction. Right knee is stable to valgus stress in extension and at 30%. Right knee is stable to varus stress in extension and at 30%. Negative anterior drawer, 1A Lachman test and negative pivot shift test. Negative posterior drawer test and reverse pivot shift test. There is 1+ effusion in the right knee joint. Medial joint is painful to palpation.
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:
836.2 Current Tear of Cartilage or Meniscus of Knee Not Elsewhere Classified
Diagnostic/Lab:
XXX
MRI KNEE RT
Prescription:
1Tramadol Hcl 50 Mg Tablet SIG: one as needed at bed time for pain QTY: 30.00
Care Plan:
Patient Education/Counseling:
xxx 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 has been eating fruits and vegetables for six (6) months or longer (maintenance stage).
Has patient quit smoking/never smoked? Patient has not smoked for six (6) months or longer (Maintenance Stage).
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) BMI over normal range for age and gender. Provided Choose My Plate for nutrition and exercise education. Instructed xxx to establish realistic weight loss goals. Ideal BMI range discussed. Dental Care:Instructed to receive regular dental check-up at least once per year.
Medications: Instructions given to patient on risk, benefits, potential side effects, drug interactions, instructions for properly taking the medication(s), and consequence(s) of not taking the new prescription medication(s) as prescribed. The provider assessed the patient-family understanding of the information about the medication(s) and the patient-family understands the instructions for the new medication(s). Current medications reviewed with patient including side effects, benefits and risks. Proper method of taking discussed. Patient-Family understands instructions for the medication(s).
FOLLOW-UP: If worse or no better return to clinic in 20 days. Return sooner if the condition changes, worsens, or does not resolve. If condition worsens, call XXXXX to schedule an appointment with your primary care provider, or after hours, call on-call provider at XXXX. All questions were addressed. Patient/caretaker appears to clearly understand and is comfortable with careplan. Discussed treatment plan and expected course..
REFUSAL: xxx 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.
Care Coordination/Case Management:
Care Coordinator/Case Manager working with patient today is XXX, LPN. Case Management Care Plan: Met with the patient while she was her regarding a fall on her Right Knee, pt states she is okay other than he knee injury, pt denies any problems with getting her medications at this time/XX
Educational Handouts:
(1) Be Physically Fit
Source: Department of Health and Senior Services and U.S. Department of Agriculture
http://www.choosemyplate.gov
(2) Lets Eat for the Health of it
Source: Department of Health and Senior Services and U.S. Department of Agriculture
http://www.choosemyplate.gov
Followup:
This visit note has been electronically signed off by following providers.
This visit note has been electronically signed off by XXX, DO on 04/23/2013 at 04:13 PM.
Can anyone else review this and let me know what you have come up with in auditing this note for the History, Examination, and MDM?
Visit Note - Office Visit
Provider: DO
Encounter Date: Apr 23, 2013
Patient: xxx
Gender: Female DOB: xxx Age: 58 year 2 month
Race: White
Address: xxx
Insurance: xxxx
Patient came to office for an office visit.
Nursing Staff:
Patient assisted by xxx, LPN. Previsit Planning completed by xxxx, LPN.
Vital Signs:
Time: 10:12 AM
Weight: 173 lbs 12 oz
Height: 63"
BMI: 30.77
BSA: 1.87
Temperature: 96.7 F (Tympanic)
Waist Circumference: 39 inches
BP: 134/84(Left Arm)(Sitting)
Pulse: 64(Apical)(Sitting)(Regular)
Respiration: 20
Oxygen: 98(Room air)
Chief Complaint:
Ms. xxx is here for further evaluation of right knee. Patient had a fall. – by XXX,LPN
Current Medication:
1 Lidoderm 5% Patch %(700 Mg/patch) Apply 1 in 12 hors then off for 12 hours
2 Freestyle Freedom Glucometer Kit
3 Freestyle Freedom Test Strips Use 1 strip twice daily as directed
4 Nasonex 50 Mcg Nasal Spray Mcg/actuation Inhale 2 sprays in each nostril once daily
5 Atenolol 50 Mg Tablet Take 1 daily
6 Lancets Use one 3 times daily and as needed
7 Wrist Blood Pressure Cuff Use daily or as directed
8 Loratadine 10 Mg Tablet Take 1 tablet daily as needed for allergies
9 Paroxetine Hcl 30 Mg Tablet Take 1 daily
10 Iron 325 Mg Tablet (65 Mg Iron) Take 1 daily
11 Welchol 625 Mg Tablet 3 TABS TWICE A DAY
12 Torsemide 20 Mg Tablet Take 1 daily
13 Fish Oil 1,200 Mg Softgel 360-1,200 take 1 daily
14 Zantac 300 Mg Tablet Take 1 tablet(s) daily
15 Gabapentin 100 Mg Capsule Take 1 three times a day
16 Lantus 100 Units/ml Vial Unit/ml Take 5 units daily at bedtime
17 Cozaar 50 Mg Tablet 1 daily
18 Reglan 10 Mg Tablet Take 1/2 tab four times daily
19 Amlodipine Besylate 5 Mg Tab 1 daily
20 Calcium,magnesium,zinc 1 AM ON EMPTY STOMACH AND 1 @ HS
21 Methocarbamol 750 Mg Tablet Take as needed
22 Norvasc 5 Mg Tablet Take 1 daily
23 Ropinirole Hcl 2 Mg Tablet Take 1 daily at bedtime
24 Thiamine 100 Mg Tablet 1 po daily
25 Vitamin B12 2,000 Mcg Tab Sa (OTC) Take 1 daily
26 Women's 50+ Advanced Capsule 400 Mcg (OTC) Take 1 daily
27 Lamictal 25 Mg Tablet (Other MD) take 1 tab x2 daily for week1 and 2, then 2 tabs x2 daily for weeks 3 and4, then 3 tabs x 2 daily for weeks 5 and 6, 4 tabs x2 daily for week 7 and onwards
28 Vit D2 1.25 Mg (50,000 Unit) (Dr LARDIZBAL) 1 weekly x 12 doses
29 Protonix Dr 40 Mg Tablet (Other MD) Take 1 twice daily
Allergy/Adverse Reaction:
Adhesive Tape, Iodine, Large dose aspirin, Niacin, Statins, NSAIDS
Social History:
Social history reviewed and unchanged on Apr 23, 2013 by XXX, LPN.
Diet type: low sugar diet.
Debra used to use tobacco products. She quit smoking 1973.
She denies alcohol use.
Pre-SBIRT:Completed on Oct 16, 2012. When was the last time you had 4 standard drinks in a day or night? Was that within the last three months? No. In the last 12 months, did you ever find yourself drinking more than you meant to? No. In the last 12 months, did you smoke pot, use another street drug, or use a prescription painkiller, stimulant, or sedative for a non-medical reason? No.
She denies recreational drug use.
Patient is divorced once.
Patient lives with her 1 granddaughter and 1 grandson.
Patient is participating in routine exercise.
Caffeine intake consists of She denies drinking caffeinated coffee. She denies drinking caffeinated soda., She denies drinking caffeinated tea.
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 Apr 23, 2013 by XXX, LPN. Positive Family History: (+) diabetes type 2, (+) epilepsy, (+) Heart Disease, (+) malignancy (+) brain cancer in a brother, (+) breast cancer, in 2 aunts, (+) cervical cancer, in an aunt, (+) lung cancer, in a brother, (+) stomach cancer, in an aunt and (+) Heart Attack in father, in paternal grandfather.
Medical History:
Reviewed and unchanged on Apr 23, 2013: allergies, current medication list (including problems or difficulties taking the medications were documented as needed), medical history, immunizations, by LPN.
Her last ER visit was on Feb 9, 2013 for Low blood sugar, dehydration, possible seizure, UTI.
Xxx has not seen a specialist since last visit.
Does not see a specialist at this time.
No medical records are needed at this time.
Collaborative Tracking: .
Diabetes: Has had a diabetic eye exam on Aug 2012. Patient has not had a dental exam in the past year. Patient had a diabetic foot exam on Oct 16, 2012. Patient had a HA1C Mar 7, 2013. Patient had a lipid screening Mar 7, 2013. Annual microalbumin testing on Oct 16, 2012. Patient not taking daily aspirin. Most recent flu shot done on Oct 10, 2011. Most recent pneumonia vaccination done on Oct 10, 2011.
Preventative Screenings: Has had an preventative eye exam on 2012. Patient had a preventative dental exam on 2012..
Angina. Date of diagnosis is unknown.
Hypercholesterolemia. Date of diagnosis is unknown. Pt did not tolerate statins and had severe flushing with Niacin (however, she did not take an aspirin with it).
Hypertension. Date of diagnosis is unknown.
Gastroesophageal reflux. Date of diagnosis is unknown.
Irritable bowel syndrome. Date of diagnosis is unknown.
Peptic ulcer disease. Date of diagnosis is unknown.
Back pain. Date of diagnosis is unknown.
Carpal tunnel syndrome. Date of diagnosis is unknown.
Lumbar disc disease. Date of diagnosis is unknown.
Restless legs syndrome. Date of diagnosis is unknown.
Patient has appt. for EEG AND MR 1-30-12.
Obesity. Date of diagnosis is unknown.
Cushing's disease. Date of diagnosis is unknown.
Type 2 diabetes. Date of diagnosis is unknown.
Arthritis. Date of diagnosis is unknown.
Fibromyalgia. Date of diagnosis is unknown.
Surgeries- Procedures:
COLONOSCOPY: Colonoscopy 2005,.
Gallbladder surgery Dec 2012,.
Hysterectomy in 1992 (abdominal , complete, due to bleeding.).,.
Tonsillectomy, Back: She had discectomies and/or laminectomies on all 5 lumbar vertebrae in 2003.
Right rotator cuff repair in 1990.
Heart cath.
.
Ob/Gyn History:
OBGYN history was reviewed & updated on Mar 14, 2013 by XXX, LPN.
Date of LMP:1992.
Gravida 5 para 3 .
xxx not currently pregnant.
xxx is not breastfeeding.
Hx of Gyn DX: Significant gynecologic illness(es) the patient had include endometriosis.
No history of STI exposure or disease.
Procedures: tubal ligation done on 1980.
She had a mammogram on Nov 16, 2011 which showed normal result (ultral sound recommened due to lump felt on left breast).
Performs self breast exam. Montlhy.
Patient is not sexually active. Last Pap--1995.
HPI:
58 year 2 month age old patient is here for patient fell 3 and 1/2 weeks ago and she has right knee pain and pain radiating up her right leg. She fell up some steps. She denies unconciousness. Patient did not go to the ER. Respiratory: She denies shortness of breath, cough, pain with deep breath, wheezing or any other complaints related to respiratory system. Cardiovascular: She denies chest pain, palpitations, fainting spells, pedal edema or shortness of breath. Genitourinary: No complaints of pain with urination, frequency, urgency or hematuria.
PHQ reviewed.No follow-up or treatment needed at this time.
ROS:
See HPI.
Current medications reviewed. XXX claims she is compliant with medications and has experienced no side effects. Past medical history, family history, and social history reviewed.
Examination:
Musculoskeletal:
KNEE: Inspection of the right knee joint reveals no deformity, swelling, quadriceps atrophy, asymmetry or misalignment. Range of motion is restricted with internal rotation and external rotation. No pain is noted during flexion, extension, internal rotation, external rotation, adduction and abduction. Right knee is stable to valgus stress in extension and at 30%. Right knee is stable to varus stress in extension and at 30%. Negative anterior drawer, 1A Lachman test and negative pivot shift test. Negative posterior drawer test and reverse pivot shift test. There is 1+ effusion in the right knee joint. Medial joint is painful to palpation.
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:
836.2 Current Tear of Cartilage or Meniscus of Knee Not Elsewhere Classified
Diagnostic/Lab:
XXX
MRI KNEE RT
Prescription:
1Tramadol Hcl 50 Mg Tablet SIG: one as needed at bed time for pain QTY: 30.00
Care Plan:
Patient Education/Counseling:
xxx 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 has been eating fruits and vegetables for six (6) months or longer (maintenance stage).
Has patient quit smoking/never smoked? Patient has not smoked for six (6) months or longer (Maintenance Stage).
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) BMI over normal range for age and gender. Provided Choose My Plate for nutrition and exercise education. Instructed xxx to establish realistic weight loss goals. Ideal BMI range discussed. Dental Care:Instructed to receive regular dental check-up at least once per year.
Medications: Instructions given to patient on risk, benefits, potential side effects, drug interactions, instructions for properly taking the medication(s), and consequence(s) of not taking the new prescription medication(s) as prescribed. The provider assessed the patient-family understanding of the information about the medication(s) and the patient-family understands the instructions for the new medication(s). Current medications reviewed with patient including side effects, benefits and risks. Proper method of taking discussed. Patient-Family understands instructions for the medication(s).
FOLLOW-UP: If worse or no better return to clinic in 20 days. Return sooner if the condition changes, worsens, or does not resolve. If condition worsens, call XXXXX to schedule an appointment with your primary care provider, or after hours, call on-call provider at XXXX. All questions were addressed. Patient/caretaker appears to clearly understand and is comfortable with careplan. Discussed treatment plan and expected course..
REFUSAL: xxx 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.
Care Coordination/Case Management:
Care Coordinator/Case Manager working with patient today is XXX, LPN. Case Management Care Plan: Met with the patient while she was her regarding a fall on her Right Knee, pt states she is okay other than he knee injury, pt denies any problems with getting her medications at this time/XX
Educational Handouts:
(1) Be Physically Fit
Source: Department of Health and Senior Services and U.S. Department of Agriculture
http://www.choosemyplate.gov
(2) Lets Eat for the Health of it
Source: Department of Health and Senior Services and U.S. Department of Agriculture
http://www.choosemyplate.gov
Followup:
This visit note has been electronically signed off by following providers.
This visit note has been electronically signed off by XXX, DO on 04/23/2013 at 04:13 PM.
