Wiki E/m level

[HBULLOCK]

I would like to get an opinion on this. There is no PE included in visit :

Chief Complaint
first B-12 injection. dr farahmand neuro did test and it was low. needs 1000 mcg qoweek for 2 months. mom will give other doses after being shown how to do it by nursing here today.

on lamictal, folic acid. for sz disorder. last sz 1996.

also needs flu vaccine and pneumoccal.

Vital Signs
AGE 24y10.2m
TEMPERATURE 99.6 F
BLOOD PRESSURE 116/68
WEIGHT 115.6 lb
BMI 19.7

Assessment and Plan
Assesment

low B-12



Plan:

1000 mcg B-12 today.

mom taught how to give others

flu vaccine and pneumococcal vaccine today.

Doctor put this note in after seeing patient briefly. Thanks

 

[hewitt]

Does not sound to me as though the doctor performed any of the services.... Did s/he?

 

[HBULLOCK]

The doctor went in to see them and spoke briefly about the injection. He ordered that to be done by nurse and also the other two imms.

 

[hewitt]

I think you might want to consider only coding the "J" codes, and the administraion CPTs.

 

[HBULLOCK]

Thanks for your input. Helen