I am being told that this would be 99212. I don't understand why it would only be 99212. What is throwing me off was in Plan ED or Urgent care on Risk part. Problem address I have as 1 undiagnosed new problem with uncertain prognosis minimal or none date and risk if she did not urgent care only the E/R I would said High and ended with 99214.
CHIEF COMPLAINT
• Telemedicine by Live Video and Audio
The Chief Complaint is::abnormal heart rhythm.
REASON FOR VISIT
This visit was completed using a live video and audio tool due to the restrictions of the COVID-19 pandemic. All issues as below were discussed and addressed but no physical exam was performed unless allowed by visual confirmation using the live video and audio tool. If it was felt that the patient should be evaluated in clinic then they were directed there. Patient verbally consented to visit.
• Telemedicine originating site: patient located at home
; • Telemedicine remote site: provider located at home
; • Patient contacted: Time call started:1543
• Patient contacted: Time call ended:1553
HISTORY OF PRESENT ILLNESS
Dawn Dick is a 41 year old female.
° No systemic symptoms ° No fever
• Chest pain or discomfort
• Pulmonary symptoms
° No gastrointestinal symptoms ° Normal appetite
° No dizziness
Pt reports that she has been having chest pain and feeling like she isn't getting enough oxygen for 4 days. Pt reports that 2 days ago her left arm went numb and was very painful. Pt reports using goody powder which helped the pain but she still feel like her heart has an abnormal rhythm and is uncomfortable. No further treatment attempted. Pt reports that she didn't go to the ER because the pain was not sharp
REVIEW OF SYSTEMS
Systemic: No systemic symptoms, no fever, and no chills.
Head: No headache.
Neck: No neck symptoms.
Otolaryngology: No otolaryngology symptoms.
Cardiovascular: Cardiovascular symptoms.
Pulmonary: Pulmonary symptoms.
Gastrointestinal: No gastrointestinal symptoms and normal appetite.
Psychological: No feelings of hopelessness. No loss of pleasure from usual activities.
PHYSICAL FINDINGS
General Appearance:
° Normal. ° Well-appearing. ° Alert. ° Well developed. ° In no acute distress.
Lungs:
° Unlabored respiration.
Neurological:
° Level of consciousness was normal. ° No disorientation was observed. ° Mental status was normal.
Speech: ° Normal.
Psychiatric:
Appearance: ° Normal.
Mood: ° Euthymic.
Affect: ° Normal.
Thought Content: ° Revealed no impairment.
ASSESSMENT
• Chest pain
PLAN
• Treatment plan:
Parent/Patient Understands Information.
-pt advised to go to ED or urgent care asap
CHIEF COMPLAINT
• Telemedicine by Live Video and Audio
The Chief Complaint is::abnormal heart rhythm.
REASON FOR VISIT
This visit was completed using a live video and audio tool due to the restrictions of the COVID-19 pandemic. All issues as below were discussed and addressed but no physical exam was performed unless allowed by visual confirmation using the live video and audio tool. If it was felt that the patient should be evaluated in clinic then they were directed there. Patient verbally consented to visit.
• Telemedicine originating site: patient located at home
; • Telemedicine remote site: provider located at home
; • Patient contacted: Time call started:1543
• Patient contacted: Time call ended:1553
HISTORY OF PRESENT ILLNESS
Dawn Dick is a 41 year old female.
° No systemic symptoms ° No fever
• Chest pain or discomfort
• Pulmonary symptoms
° No gastrointestinal symptoms ° Normal appetite
° No dizziness
Pt reports that she has been having chest pain and feeling like she isn't getting enough oxygen for 4 days. Pt reports that 2 days ago her left arm went numb and was very painful. Pt reports using goody powder which helped the pain but she still feel like her heart has an abnormal rhythm and is uncomfortable. No further treatment attempted. Pt reports that she didn't go to the ER because the pain was not sharp
REVIEW OF SYSTEMS
Systemic: No systemic symptoms, no fever, and no chills.
Head: No headache.
Neck: No neck symptoms.
Otolaryngology: No otolaryngology symptoms.
Cardiovascular: Cardiovascular symptoms.
Pulmonary: Pulmonary symptoms.
Gastrointestinal: No gastrointestinal symptoms and normal appetite.
Psychological: No feelings of hopelessness. No loss of pleasure from usual activities.
PHYSICAL FINDINGS
General Appearance:
° Normal. ° Well-appearing. ° Alert. ° Well developed. ° In no acute distress.
Lungs:
° Unlabored respiration.
Neurological:
° Level of consciousness was normal. ° No disorientation was observed. ° Mental status was normal.
Speech: ° Normal.
Psychiatric:
Appearance: ° Normal.
Mood: ° Euthymic.
Affect: ° Normal.
Thought Content: ° Revealed no impairment.
ASSESSMENT
• Chest pain
PLAN
• Treatment plan:
Parent/Patient Understands Information.
-pt advised to go to ED or urgent care asap