carriganm
Networker
Can you count acute problems as a new problem in the MDM? For example:
HPI:
Pt presents today with c/o poison oak rash. She has used OTC cortisone and calamine lotion and essential oils. She first noticed it on her right arm on Saturday. She was holding and hugging her sister's dogs who had been out in the poison oak. The rash has spread to her left arm, right leg and now on her chin.
Assessment and Plan:
1. Contact dermatitis - Recommend use of caladryl. Rx written for pred pak.
L25.9: Unspecified contact dermatitis, unspecified cause
prednisone 10 mg tablet - Take by oral route. as instructed. See note. Qty: 21 tablet(s) Refills: 0 Pharmacy: CVS 16159 IN TARGET Note to Pharmacy: Day 1: 6 tablets Day 2: 5 tablets Day 3: 4 tablets Day 4: 3 tablets Day 5: 2 tablets Day 6: 1 tablet
HPI:
Pt presents today with c/o poison oak rash. She has used OTC cortisone and calamine lotion and essential oils. She first noticed it on her right arm on Saturday. She was holding and hugging her sister's dogs who had been out in the poison oak. The rash has spread to her left arm, right leg and now on her chin.
Assessment and Plan:
1. Contact dermatitis - Recommend use of caladryl. Rx written for pred pak.
L25.9: Unspecified contact dermatitis, unspecified cause
prednisone 10 mg tablet - Take by oral route. as instructed. See note. Qty: 21 tablet(s) Refills: 0 Pharmacy: CVS 16159 IN TARGET Note to Pharmacy: Day 1: 6 tablets Day 2: 5 tablets Day 3: 4 tablets Day 4: 3 tablets Day 5: 2 tablets Day 6: 1 tablet