E&M, Preventative or both
I was wondering if someone could help me with this. Some feel both E&M and Preventative should be attached, others in the office say just E&M. Who is right
Subjective:
CC:
1. 18 yo female presents for annual gyn and Depo. Currently sexually active x 1 male x 1 week. Current Partner Denies: STDs, IVDU, Other Partner, Bisexual. Using condoms, though h/o unprotected sex 6 days ago. h/o irreg menses, never skips more then 2 mos, at times 2 x mos, but rare. . 2. Denies current meds.
HPI:
New symptom(s):
No complaints, unless otherwise noted.
Alcohol/Tobacco/Drug Use:
Smoking status Never smoked. Alcohol use none. Drug use none.
GYN History:
Menses:
4/19/12, irregular menses
. Last Pap: never. Abnormal pap smear: none. Menarche: 10 years. Menopause: N/A. Last mammogram: N/A. Breast complaints: none. Breast self-exam: discussed BSE. Gravida 0. Para 0.
Education/Counseling:
Education/counseling provided: Reproductive/life planning, Contraception, Infertility, Desires pregnancy, Pregnancy, Sterilization, HIV risk, Immunization, Hypertension, Nutri/Folate, STD, Smoking, PAP, Sexual coercion, ECP, BSE, Options counseling. Parental involvement discussed (if teen): N/A.
Medical History: Irregular Heart Beat - w/u as child, told will not interfere with lifestyle..
Gyn History: Periods : Irregular, never skips >2 mos, rarely 2x mos.. Sexual activity currently sexually active, with men. Last pap smear date Never. Sexually Transmitted Diseases (STDs) none. Birth control condoms. Menarche: age of onset 10.
OB History: Total pregnancies 0. Total living children 0.
Surgical History: T&A .
Family History:
Social History:
Medications: None
Allergies: N.K.D.A.
Objective:
Vitals: Pain scale 0 1-10, BP 122/88 mm Hg, Ht 63 in, Wt 173 lbs, BMI 30.64 Index, Wt % 93.69 %, BMI % 95.05 %, Ht % 31.25 %.
Past Orders:
Examination:
General Examination:
NECK/THYROID: no thyromegaly, no masses. HEART: no murmurs, regular rate and rhythm. LUNGS: clear to auscultation bilaterally, no wheezes, rales, rhonchi. ABDOMEN: no guarding, no rebound, non-tender, no masses. EXTREMITIES: no varicosities, no edema.
Gynecological:
BREASTS: normal, no lymph adenopathy, no lumps palpated bilaterally, no nipple discharge, no skin changes, non-tender. EXTERNAL GENITALIA: introitus normal, no erythema, no lesions. VAGINA: clear discharge, healthy pink mucosa without any lesions, normal. CERVIX: no discharge, no cervical movement tenderness, no lesions. UTERUS: normal size, shape and consistency, non-tender to exam, no obvious masses. ADNEXA: adnexa normal with no masses and nontender to exam bilateraly. RECTUM: not examined.
Family Planning - GRANT REQUIRED:
AFPC data (click here on green text to complete): Present BCM: Male Condom, Primary prescribed BCM: 3-Month Hormonal Injection (Depo-Provera), Secondary prescribed BCM: No Method (e.g., partner sterile), BC contraindications? no, CBE performed: yes, Breast referral provided: N/A, ABC Counseling provided: Yes, First HIV test? Yes, Other supplies provided: condoms.
Assessment:
Assessment:
1. General counseling for initiation of other contraceptive measures - V25.02
2. Routine gynecological examination - V72.31
Plan:
1. General counseling for initiation of other contraceptive measures
Annual GYN Exam: 1) Pap, gc/chl, RPR, HIV. 2) BSE taught. 3) Routine healthcare reviewed. 4) RTC 1 year.
Depo Rx and Counseling: 1) Consent signed. 2) Risks/ Benefits reviewed. SE reviewed. 3) Calcium encouraged. 4) Injection given. Condoms x 1 week. 5) h/o unprotected sex 6 days ago, pregnancy and Depo reviewed, advised if no bleeding to to urine preg in 3.5 weeks. 6) RTC 3 mos.
2. Routine gynecological examination
LAB: Pregnancy Test, Urine negative
LAB: Urine chem strip ph 5.0, sp gr 1020, prt trc
LAB: RPR
LAB: Chlamydia/GC Amplification
LAB: HIV FingerStick Lab negative
LAB: Hemoglobin 13.7
3. Others
Post-Education/Counseling provided on breast and cervical cancer screening, reproductive health, STD/HIV risk factors, symptoms and treatment. Exam & follow-up instructions reviewed as necessary. Emergency information given. Patient states understanding.
I was wondering if someone could help me with this. Some feel both E&M and Preventative should be attached, others in the office say just E&M. Who is right
Subjective:
CC:
1. 18 yo female presents for annual gyn and Depo. Currently sexually active x 1 male x 1 week. Current Partner Denies: STDs, IVDU, Other Partner, Bisexual. Using condoms, though h/o unprotected sex 6 days ago. h/o irreg menses, never skips more then 2 mos, at times 2 x mos, but rare. . 2. Denies current meds.
HPI:
New symptom(s):
No complaints, unless otherwise noted.
Alcohol/Tobacco/Drug Use:
Smoking status Never smoked. Alcohol use none. Drug use none.
GYN History:
Menses:
4/19/12, irregular menses
. Last Pap: never. Abnormal pap smear: none. Menarche: 10 years. Menopause: N/A. Last mammogram: N/A. Breast complaints: none. Breast self-exam: discussed BSE. Gravida 0. Para 0.
Education/Counseling:
Education/counseling provided: Reproductive/life planning, Contraception, Infertility, Desires pregnancy, Pregnancy, Sterilization, HIV risk, Immunization, Hypertension, Nutri/Folate, STD, Smoking, PAP, Sexual coercion, ECP, BSE, Options counseling. Parental involvement discussed (if teen): N/A.
Medical History: Irregular Heart Beat - w/u as child, told will not interfere with lifestyle..
Gyn History: Periods : Irregular, never skips >2 mos, rarely 2x mos.. Sexual activity currently sexually active, with men. Last pap smear date Never. Sexually Transmitted Diseases (STDs) none. Birth control condoms. Menarche: age of onset 10.
OB History: Total pregnancies 0. Total living children 0.
Surgical History: T&A .
Family History:
Social History:
Medications: None
Allergies: N.K.D.A.
Objective:
Vitals: Pain scale 0 1-10, BP 122/88 mm Hg, Ht 63 in, Wt 173 lbs, BMI 30.64 Index, Wt % 93.69 %, BMI % 95.05 %, Ht % 31.25 %.
Past Orders:
Examination:
General Examination:
NECK/THYROID: no thyromegaly, no masses. HEART: no murmurs, regular rate and rhythm. LUNGS: clear to auscultation bilaterally, no wheezes, rales, rhonchi. ABDOMEN: no guarding, no rebound, non-tender, no masses. EXTREMITIES: no varicosities, no edema.
Gynecological:
BREASTS: normal, no lymph adenopathy, no lumps palpated bilaterally, no nipple discharge, no skin changes, non-tender. EXTERNAL GENITALIA: introitus normal, no erythema, no lesions. VAGINA: clear discharge, healthy pink mucosa without any lesions, normal. CERVIX: no discharge, no cervical movement tenderness, no lesions. UTERUS: normal size, shape and consistency, non-tender to exam, no obvious masses. ADNEXA: adnexa normal with no masses and nontender to exam bilateraly. RECTUM: not examined.
Family Planning - GRANT REQUIRED:
AFPC data (click here on green text to complete): Present BCM: Male Condom, Primary prescribed BCM: 3-Month Hormonal Injection (Depo-Provera), Secondary prescribed BCM: No Method (e.g., partner sterile), BC contraindications? no, CBE performed: yes, Breast referral provided: N/A, ABC Counseling provided: Yes, First HIV test? Yes, Other supplies provided: condoms.
Assessment:
Assessment:
1. General counseling for initiation of other contraceptive measures - V25.02
2. Routine gynecological examination - V72.31
Plan:
1. General counseling for initiation of other contraceptive measures
Annual GYN Exam: 1) Pap, gc/chl, RPR, HIV. 2) BSE taught. 3) Routine healthcare reviewed. 4) RTC 1 year.
Depo Rx and Counseling: 1) Consent signed. 2) Risks/ Benefits reviewed. SE reviewed. 3) Calcium encouraged. 4) Injection given. Condoms x 1 week. 5) h/o unprotected sex 6 days ago, pregnancy and Depo reviewed, advised if no bleeding to to urine preg in 3.5 weeks. 6) RTC 3 mos.
2. Routine gynecological examination
LAB: Pregnancy Test, Urine negative
LAB: Urine chem strip ph 5.0, sp gr 1020, prt trc
LAB: RPR
LAB: Chlamydia/GC Amplification
LAB: HIV FingerStick Lab negative
LAB: Hemoglobin 13.7
3. Others
Post-Education/Counseling provided on breast and cervical cancer screening, reproductive health, STD/HIV risk factors, symptoms and treatment. Exam & follow-up instructions reviewed as necessary. Emergency information given. Patient states understanding.
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