Bullets for E&M

todd5400

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Opinions please on how many bullets you see!

No specific CC is listed

HPI: Patient is a 33 y/o male, s/p assault with positive loss of consciousness who was brought to the ER with a right sided scalp laceration which was staples in ER. Ct of head shows linear nondisplaced parietal skull fx with small amount of intracranial air. No reported seizure ativity or mental status changes.

Mary
 

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Bullets for an Exam?

Is this the whole note?

Is this a new or established patient, consult or other?

Shown as is:

HPI: Patient is a 33 y/o male, s/p assault with positive loss of consciousness who was brought to the ER with a right sided scalp laceration which was staples in ER. Ct of head shows linear nondisplaced parietal skull fx with small amount of intracranial air. No reported seizure ativity or mental status changes.

CC: I would use s/p assault w/ + loss of consciousness
HPI: Location - right sided scalp lac
ROS: (2) you could use no seizures (neuro) no mental status changes (psych)
PFSH: none
Problem Focused History

Exam: None

MDM:
New problem, no work up (that I can tell)
Review CT
Acute Complicated Injury - Moderate Risk

What do you think?
 
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todd5400

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This is an H & P for hospital and I was questioning the bullets for the cc and hpi portion only. Sorry for confusion
Mary
 

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I see - well I get :

CC: I would use s/p assault w/ + loss of consciousness
HPI: Location - right sided scalp lac


For the lowest level for an admit H&P, you need to have a detailed history - which the documentation you have provided does not support a detailed history
 
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Is the ROS & PMFSH separate?

I'm going to assume that ROS and PMFSH are separately recorded.

I'm really stretching for this, but ...

CC: S/p assault w/ LOC
HPI: location (rt scalp, skull), quality (nondisplaced FX), severity (small amount of air), Assoc Signs (no seizure activity)

If the doc had only said WHEN the assault occured, you'd clearly have duration.

F Tessa Bartels, CPC, CPC-E/M
 
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