Wiki Help with scoring HPI

[arrana]

I am auditing charts for our providers, and have come across some very poor documentation. I would appreciate feedback on how you would best score this note. There is no ROS listed anywhere, but we have a fairly comprehensive PFS history.

Reason for Appointment
1. 2 wk fu
2. Following up on labs
3. Pt states that he takes a beta blocker, pt forgot to bringwith his as he doesn't remember the name
4. pt needs a new Epi Pen
5. would like a flu shot. Nurse -Flu, Medicare patient

History of Present Illness:
second visit with Pt has Hx of NIDDM, hyperlipidemia, gout and fatty liver, recent labs were reassuring and Pt remains very active. He has had struggles with depression but last vist felt staying on MEDS was good choice and working with therapist.

Examination
Brief exam:
General Appearance Pleasant, NAD, Well-developed, well-nourished, No Resp Distress, AOX3. NECK: supple. PSYCHIATRIC: good discussion concerns discussed does not tolerate statins .

I'm not finding a whole lot to work with but would appreciate input from others. This is a typical note for this provider.

Thanks,
Arrana

 

[MikeEnos]

I would advise against cross-posting the same question in different forums.

Reviewing this, you seem to have a brief HPI. The History overall appears to be Expanded Problem Focused. ROS wasn't separately listed but they did review depression. The exam appears to be Expanded Problem Focused (Constitutional, Respiratory, Neck, Psych.) Without seeing the Assessment/Plan I'm guessing this is a 99213.