jifnif
Expert
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
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