Wiki Help W/ Subsequent Note

[jifnif]

Sorry to bother you all AGAIN w/ another note but I am having a hard time w/ our hospitalists note. I am pasting a copy so you can see what I mean. Can i even count this note as a 99231? And on top of it all, our drs pull info from the previous dos....is this allowable???? Thanks.

PLAN: []

cont to monitor
adc

PROBLEM LIST: []

Rash/bullae- likely drug reaction
MDR Proteus UTI
DM2 - A1c = 6.1% - good outpt control
HTN
Dementia
ARF on CKD

SUBJECTIVE: []

Pt non-verbal. no vents per nursing.

OBJECTIVE: []


Item Value Date Time
Patient Temperature 97.4 degrees F L 7/22/09 0832
Pulse Rate 72 bpm 7/22/09 0832
Respiratory Rate 20 bpm 7/22/09 0832
Blood Pressure Assessment 142/70 7/22/09 0832
Bedside Pulse Oximetry 96 % 7/22/09 0900
White Blood Count 16.1 K/mm3 H 7/22/09 0550
Hemoglobin 10.2 gm/dL L 7/22/09 0550
Platelet Count 167 K/mm3 7/22/09 0550
Sodium Level 149 mmol/L H 7/21/09 0500
Potassium Level 4.6 mmol/L 7/21/09 0500
Chloride Level 120 mmol/L H 7/21/09 0500
Carbon Dioxide Level 22.3 mmol/L 7/21/09 0500
Blood Urea Nitrogen 97 mg/dL *H 7/21/09 0500
Creatinine 2.30 mg/dL H 7/21/09 0500
Percent Meal Consumed 100% 7/22/09 0833
Percent Meal Consumed 100% 7/21/09 1700
Percent Meal Consumed 100% 7/21/09 1158
Bedside Blood Glucose 266 mg/dl H 7/21/09 1624
Bedside Blood Glucose 181 mg/dl H 7/21/09 2002
Bedside Blood Glucose 190 mg/dl H 7/22/09 0631


PHYSICAL EXAM:

General: No Apparent distress
Heart: Regular rate and rythym, no murmur, rub or gallop
Lungs: clear to auscultation bilaterally without wheezes, rales or rhonci
Abdomen: Soft, non-tender, nondistended, + bowel sounds
Extremities: warm and dry without cyanosis, clubbing or edema, 2+peripheral pulses
skin: petechial, coalescing rash on lower abdomen new today

 

[LLovett]

The set up of this note is confusing but I'm pretty sure there is no chief complaint. I have no idea why he is seeing this patient. If there is no chief complaint there is no visit. You could try a 99499 and send with notes.

Just my opinion,

Laura, CPC, CEMC

 

[FTessaBartels]

Inpatient Subsequent Visit

I agree with Laura ... I can't figure out what the chief complaint is.

If it's separately recorded ... yes, you'd have enough for a 99231 ... you only need 2 of 3 elements for subsequent visit. You have an EPF exam and SF MDM.

BUT where is that chief complaint?

And, yes, especially with inpatients you can repeat history, but what is really relevant for subsequent hospital visits is the INTERVAL history ... i.e. what happened since your last visit?

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[jifnif]

thanks. that helps alot. so it is okay to copy and paste history but what about the plan or what is going on w/ the pt. ie, impression and plans?