Help - Is this a AWV

perkins05

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New Orleans
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Well Adult Exam - Male *

Associated Diagnoses: Annual exam

Chief Complaint
CHIEF COMPLAINT
yearly

Well Adult History
Well Adult History
The patient presents for well adult exam. The patient's general health status is described as poor. The patient's diet is described as tube fed. Exercise: none. Associated symptoms consist of none.

Review of Systems
Constitutional: Negative, No weakness, No fatigue.
Eye: Negative, No recent visual problem, No blurring, No visual disturbances.
Respiratory: No shortness of breath, No cyanosis, No apnea.
Cardiovascular: No chest pain, No palpitations, No peripheral edema.
Gastrointestinal: No nausea, No vomiting, No constipation.
Genitourinary: No dysuria, No hematuria, No change in urine stream.
Endocrine: No excessive thirst, No polyuria, No excessive hunger.
Musculoskeletal: No muscle pain, No claudication.
Neurologic: Alert and oriented X4, No numbness, No tingling, No headache.

Health Status
Allergies: .
Allergic Reactions (All)
Severity not Documented
Sulfa drug (No reactions were documented)
Canceled/Inactive Reactions (All)
Severity not Documented
Sulfa (No reactions were documented)

Medications: (Selected).
Documented Medications
Documented
Isopto Homatropine 5% ophthalmic solution: 2 drop(s), Both eyes, QID, # 5 mL, 0 Refill(s), Type: Soft Stop
atropine-diphenoxylate 0.025 mg-2.5 mg oral tablet: 1 tab(s), PO, QID, PRN: for loose stools, 0 Refill(s), Type: Soft Stop
polyethylene glycol 3350 with electrolytes oral powder for solution: Instructions: use as directed
thioridazine 50 mg oral tablet: 1 tab(s) ( 50 mg ), PO, TID, # 90 tab(s), 0 Refill(s), Type: Soft Stop

Histories
Past Medical History: .
No active or resolved past medical history items have been selected or recorded.
Family History: .
Healthy adult
Mother
Family members deceased
Father

Procedure history: .
tube fed.
Social History
.
Alcohol Assessment
Never
Tobacco Assessment
Never
Substance Abuse Assessment
Never

Physical Examination
VS/Measurements
Vital Signs
CDT Temperature Oral 98.3 DegF
Peripheral Pulse Rate 70 bpm
Respiratory Rate 16 br/min
Systolic Blood Pressure 90 mmHg
Diastolic Blood Pressure 68 mmHg
Mean Arterial Pressure 75 mmHg
, Measurements from flowsheet : Measurements
CDT Height 0.00 in
Weight 0.00 lb

General: Alert and oriented, No acute distress.
Eye: Pupils are equal, round and reactive to light, Extraocular movements are intact, Normal conjunctiva, Vision unchanged.
HENT: Normocephalic, Normal hearing, No pharyngeal erythema.
Neck: Supple, Non-tender, No carotid bruit, No jugular venous distention, No lymphadenopathy, No thyromegaly.
Respiratory: Lungs are clear to auscultation, Breath sounds are equal, Symmetrical chest wall expansion.
Cardiovascular: Normal rate, Regular rhythm, No murmur, Good pulses equal in all extremities, Normal peripheral perfusion, No edema.
Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly, peg tube in place.
Lymphatics: No lymphadenopathy neck, axilla, groin.
Feet: Normal by visual exam, Normal pulses, Sensation intact, By monofilament exam.
Neurologic: Alert, Oriented.
Psychiatric: Cooperative.

Impression and Plan
Course: Progressing as expected.

Orders
Orders.
Laboratory (Requests):
TSH (Request) (Ordered)
PSA (Request) (Ordered)
Comprehensive Metabolic Panel (Request) (Ordered)
CBC w/Diff/Plt (Request) (Ordered)
Orders.


Thanks
All help is greatly appreciated:confused:
 

espressoguy

Expert
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Location
Tacoma, WA
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No, this is not an AWV.

Medicare has very specific things that are required to be documented to qualify as an AWV. This looks more like a CPE.
 
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