Here is an example of a note:
The provider billed the following CPT's: 20610,99203
CHIEF COMPLAINT: Left knee pain.
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old male who is a new patient to our practice, hasn't been here for over 3 years, and complains of left knee pain for the past 3-4 weeks that got worse over the past 1-2 weeks. He states he points to the anterior aspect of his knee just above the patella where he asks where it hurts but states it does wrap around to the back of his knee. When he tries to bend his knee more than 45 degrees, he states it hurts a lot and snaps back to where his knee hyperflexes. He denies any accident, injury, or trauma. He has tried using Aleve, ice, and heat. He is having a hard time putting weight on his left leg. He rates the pain as 8/10. He denies any fevers or chills. He has not had any surgery on the area.
The patient's past medical history, allergies, medication, past surgical history, social history, family history were discussed, are documented in the chart, reviewed by myself.
REVIEW OF SYSTEMS: General: Patient denies appetite loss, chills, fever and night sweats. Skin: Patient denies new lesions, pallor, rash and skin color changes. HEENT: Patient denies head injury, visual disturbances, hearing loss and sore throat. Respiratory: Patient denies cough, decreased exercise tolerance, difficulty breathing and wheezing. Cardiovascular: Patient denies chest pain, rapid heart rate, shortness of breath and swelling of extremities. Gastrointestinal: Patient denies abdominal pain, change in bowel habits, diarrhea, indigestion, nausea and vomiting. Musculoskeletal: Positive for that noted in history of present illness. Neurological: Patient denies dysesthesia, paresthesias, seizures, stroke and weakness. Psychiatric: Patient denies anxiety, depression, hallucinations and panic attacks. Endocrine: patient denies cold intolerance and hair changes. Hematology: Patient denies abnormal bleeding, blood clots and petechiae.
PHYSICAL EXAMINATION:
MUSCULOSKELETAL: Left knee exam reveals no effusion, no warmth, or erythema. He has tenderness to palpation of the quadriceps tendon and the VMO. He has tenderness in the popliteal space. He has about 4 degrees of terminal extension. He does not like to try to flex past 90. He has diffuse tenderness to palpation, negative patellar grind test, and negative patellar apprehension test. He has 5/5 strength and can hold his leg out straight against gravity.
DIAGNOSTICS/ASSESSMENT/PLAN:
DIAGNOSTICS:
Left knee x-rays were done today. They were done as 4 views and independently interpreted and show very mild arthritic changes with slight subchondral sclerosis with small osteophyte formation indicative of KL grade 3 changes.
ASSESSMENT:
1. Left knee pain, acute.
PLAN: I discussed the patient's physical exam and radiograph findings, and he understands. I doubt this is gout as he does not have much swelling. I do not have a definitive cause for his pain. He does have some mild to moderate arthritis. I have talked about trying an intra-articular steroid injection. If this does not work in 1-2 weeks, then we could do an MRI without contrast of the left knee to look for internal derangement. He is in agreement with this plan.
PROCEDURE: I have discussed risks and benefits with the patient, and
he would like to proceed with a left knee intra-articular steroid injection.
The left knee was prepped in sterile fashion using chlorhexidine. Once this dried off the chlorhexidine over the skin for local anesthetic, then a 22-gauge needle was inserted via a superolateral joint space, and 3 mL of 1% lidocaine without epinephrine and 2 mL of 40 mg/mL of Kenalog was injected intra-articularly. The patient tolerated the injection well. A sterile dressing was applied.
