Debridment

cnramsey

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Not sure how to code this. Does my provider need to append this note stating what they used to debride the Diabetic Ulcer? Please review note below any advice would be appreciated.

Visit Type: Follow-up Visit
Primary Provider:

CC: dressing change.

History of Present Illness:


Here f/u right ankle cellulitis with diabetic ulcer. She is completing course of Keflex and Bactrim DS. Pain is improving and there is only a very small erythema direcly at the edges of the ulcers. Culture was staph aureous.

She has been receiving silvadene/UnnaFlex/Coban dressings every 3 days with improvement, but the ulcers wounds still need to be further debrided.
We have collagenase to use with this dressing change.



Past Medical History:
Reviewed history from 12/05/2007 and no changes required:
Hypercholesterolemia
Anxiety/depression
Hypertension
Diabetes type 2

Past Surgical History:
Reviewed history from 12/05/2007 and no changes required:
TAHBSO

Family History:
Reviewed history and no changes required:

Social History:
Reviewed history from 12/08/2008 and no changes required:
Lives with daughter


Risk Factors:

Tobacco use: quit
Year quit: 1990
Pack-years: 32
Passive smoke exposure: no
HIV high-risk behavior: no
Caffeine use: Drinks coffee 1-2 times per day.
Alcohol use: no
Type: No alcohol use.
Exercise: yes
Times per week: 1-2 /wk
Type: walking
Seatbelt use: 100 %

Family History Risk Factors:
Family History of MI in females < 65 years old: yes
Family History of MI in males < 55 years old: no

Review of Systems
See HPI

Vital Signs:

Patient Profile: Years Old Female
Temp: 97.6 degrees F tympanic
Pulse rate: 80 / minute
Pulse rhythm: regular
Resp: 17 per minute
BP sitting: 120 / 82 (left arm)
Cuff size: large

Vitals Entered By:

Physical Exam

General:
well developed, well nourished, in no acute distress.
Lungs:
clear bilaterally to auscultation.
Heart:
non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
Extremities:
The largest ulcer is 1cm at 4x4cm--the other ulcers are smaller as well. Debrided dead tissue from the ulcer base. Dressed with collagenase and with UnnaFlex/Coban bandage. No LE edema and minimal erythema. Much less painful to palpation/debridement.
Psych:
alert and cooperative; normal mood and affect; normal attention span and concentration.


Impression & Recommendations:

Problem # 1: CELLULITIS (ICD-682.9)
Improving with antibiotic.
Her updated medication list for this problem includes:
Bactrim Ds 800-160 Mg Tabs (Sulfamethoxazole-trimethoprim) ..... 1 po bid for 10 days


Problem # 2: DIABETIC ULCER, RIGHT LEG (ICD-707.10)
Collagenase dressing with UnnaFlex and Coban--change on Sunday.
 

tefranklin57

Networker
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with this sentence, Debrided dead tissue from the ulcer base. I would inform the provider that all office procedures a detail descriptive note is required. Including: sit prep, approarch, instruments used, anesthesia, method, dressing applied, out come, patient tolerance, post op instructions.
 
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