I have a new provider trying to document a certain way which I can agree and disagree, can someone help to determine if this is valid documentation. This a specialty dermatology provider who is trying to just sum up everything really short. His format is not like other providers where you format HPI,EXAM, and MDM. Help!
Rosacea:
Face: few papules
-clindamycin lotion has helped with dryness
-not sure if doxycycline pills helped condition
-Elidel will help with redness and inflammation
-use with clindamycin lotion
Rash:
-v shaped rash to chest, papules
-x 4 months; red and irritated
-history of seasonal allergies
-takes claritin for relief
-apply cream prescription to chest
-We suggest using zyrtec (certirizine) pills
Irritated Seborrheic Keratosis
0.4 centimeters papules
-under breasts
-mammo scheduled for May - treatment will be deferred until then
Post removal of Irritated Seborrheic Keratosis - left upper breast - healing well - no discomfort now
Smooth scar
No treatment
Rosacea:
Face: few papules
-clindamycin lotion has helped with dryness
-not sure if doxycycline pills helped condition
-Elidel will help with redness and inflammation
-use with clindamycin lotion
Rash:
-v shaped rash to chest, papules
-x 4 months; red and irritated
-history of seasonal allergies
-takes claritin for relief
-apply cream prescription to chest
-We suggest using zyrtec (certirizine) pills
Irritated Seborrheic Keratosis
0.4 centimeters papules
-under breasts
-mammo scheduled for May - treatment will be deferred until then
Post removal of Irritated Seborrheic Keratosis - left upper breast - healing well - no discomfort now
Smooth scar
No treatment