adri3421
Networker
Ok.....so Im auditing a critical care note.....and kind of second guessing myself.....would like to get some opinions as to whether or not this would support critical care charge: 99291? Pt was discharged the next day.......
HPI: headache, n/v much improved, tolerating reg diet
CT Head: Increased Subdural Hematoma
Assessment: Increased SDH secondary to initiation of anticoagulation therapy
Plan: Discussed at length with patient the increased risks secondary to her prosthetic heart valves, and worsening hemmorrhage with anticoagulants. Will initiate antiplatelet therapy.
Critical Care Time: 35 min
HPI: headache, n/v much improved, tolerating reg diet
CT Head: Increased Subdural Hematoma
Assessment: Increased SDH secondary to initiation of anticoagulation therapy
Plan: Discussed at length with patient the increased risks secondary to her prosthetic heart valves, and worsening hemmorrhage with anticoagulants. Will initiate antiplatelet therapy.
Critical Care Time: 35 min