Another set of eyes

maine4me

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I need another set of eyes to look at this note. Does anyone see any elements of the HPI?

Assessment and Plan
Ambulatory Assessment/Plan:
Assessment/Plan:
V72.84 Pre Operative Physical Exam

Additional Plan Details:
Preop for dental procedure/cleaning - well 24 y/o female with MR. No changes to health hx. Normal baseline per parents. Depo for dysmenorrhea, otherwise no meds. Flu shot today. F/u with PCP for routine health issues/labs. F/u sooner prn.

HPI
HPI
Nursing Chief Complaint: Pre-op clearance - dental procedure - flu shot

Physician: 24 y/o female presents with parents for pre-op PE for dental check-up scheduled 11/15/11. Wisdom teeth pulled last year. No concerns. Parents deny changes to PMHx. ROS as per PE forms. No CP/SOB, no ST, cough. No behavior changes, no changes in po intake. No f/c. No rashes.
Vitals:
Height 62 in / 157.48 cm
Weight 224 lbs / 101.604698 kg
BSA 2.16 m2
BMI 41.0 kg/m2
Temperature 98.1 F / 36.72 C - Tympanic
Pulse 120
Blood Pressure 120/82, Right Arm
Personal Medical History
Personal medical history: Hx of: High cholesterol, Obesity, Mental Retardation, Other - MR with global developmental delay (unkown etiology)

Surgical History
Past Surgical History: Hx of: Other - teeth work - had general anesthesia, had eye surgery

Family History
Family history of CV disease: Positive:: FH coronary artery dis.

Social History
Social history:
Marital Status: Single
Household members: lives home with mom, dad, brother
Occupation: attends day program

Alcohol
Alcohol Intake: None

Substance Use
Substance use: Denies use

Problem List
-----

Past Medical/Surgical History
Chronic Problems:
MENTAL RETARDATION NOS
OBESITY, NOS
PURE HYPERCHOLESTEROLEM

EXAM
*****
*****
General: No acute distress. Pleasant, interactive, minimally verbal. HR recheck 90, RR 14.

HEENT: Sclera nonicteric, TM normal bilaterally, pharynx clear without exudate.

Neck: Supple, no lymphadenopathy. FROM.

Lungs: Clear to auscultation bilaterally.

Heart: Regular rate and rhythm without murmurs or rubs.

Abd: obese, soft, normal BS, no TTP.

Neuro: grossly intact.

Ext: FROM x 4 ext, strength 5/5. PPP, no c/c/e.

Skin: warm, dry, no lesions/rashes

Also, there is documentation of a request for the pre-op clearance so I will bill this as an established E/M.
 

btadlock1

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I need another set of eyes to look at this note. Does anyone see any elements of the HPI?

Assessment and Plan
Ambulatory Assessment/Plan:
Assessment/Plan:
V72.84 Pre Operative Physical Exam

Additional Plan Details:
Preop for dental procedure/cleaning - well 24 y/o female with MR. No changes to health hx. Normal baseline per parents. Depo for dysmenorrhea, otherwise no meds. Flu shot today. F/u with PCP for routine health issues/labs. F/u sooner prn.

HPI
HPI
Nursing Chief Complaint: Pre-op clearance - dental procedure - flu shot

Physician: 24 y/o female presents with parents for pre-op PE for dental check-up scheduled 11/15/11. Wisdom teeth pulled last year. No concerns. Parents deny changes to PMHx. ROS as per PE forms. No CP/SOB, no ST, cough. No behavior changes, no changes in po intake. No f/c. No rashes.
Vitals:
Height 62 in / 157.48 cm
Weight 224 lbs / 101.604698 kg
BSA 2.16 m2
BMI 41.0 kg/m2
Temperature 98.1 F / 36.72 C - Tympanic
Pulse 120
Blood Pressure 120/82, Right Arm
Personal Medical History
Personal medical history: Hx of: High cholesterol, Obesity, Mental Retardation, Other - MR with global developmental delay (unkown etiology)

Surgical History
Past Surgical History: Hx of: Other - teeth work - had general anesthesia, had eye surgery

Family History
Family history of CV disease: Positive:: FH coronary artery dis.

Social History
Social history:
Marital Status: Single
Household members: lives home with mom, dad, brother
Occupation: attends day program

Alcohol
Alcohol Intake: None

Substance Use
Substance use: Denies use

Problem List
-----

Past Medical/Surgical History
Chronic Problems:
MENTAL RETARDATION NOS
OBESITY, NOS
PURE HYPERCHOLESTEROLEM

EXAM
*****
*****
General: No acute distress. Pleasant, interactive, minimally verbal. HR recheck 90, RR 14.

HEENT: Sclera nonicteric, TM normal bilaterally, pharynx clear without exudate.

Neck: Supple, no lymphadenopathy. FROM.

Lungs: Clear to auscultation bilaterally.

Heart: Regular rate and rhythm without murmurs or rubs.

Abd: obese, soft, normal BS, no TTP.

Neuro: grossly intact.

Ext: FROM x 4 ext, strength 5/5. PPP, no c/c/e.

Skin: warm, dry, no lesions/rashes

Also, there is documentation of a request for the pre-op clearance so I will bill this as an established E/M.
I see a preventive exam - he documents "pre-op PE for dental check-up scheduled 11/15/11. Wisdom teeth pulled last year. No concerns. Parents deny changes to PMHx."

If there's no complaint, then it's not problem-oriented, so HPI is irrelevant. (If there's no 'present illness', then there can't be any history of present illness). Although the patient does have chronic conditions that the provider manages, the reason for the encounter makes it clear that she's being seen specifically for pre-op clearance, and not as part of the routine management of her chronic problems.

I'd code this as 99395, with diagnosis code V72.83, but that's just me... ;)
 
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