NESmith
Guest
Please help me with an appropriate dx code. The documentation states: CC: New pt/needs Hep b titier
HPI: Pt is seen today for her Hep B Titier required for nursing school in NY. She is just visiting over the holidays and will followup with her PCP in NY. She did not have any paper work to be filled out for her school.
Reviewed and discussed 18 ROS check-list and personal-health assessment form with patient. Please see form for details.
PE: Vitals listed. General: The patient is well developed, well nourished, in no acute distress. EYE: Conjuctivae are without erthema. SKIN: Skin is warm and dry without pallor or cyanosis. There are no rashes, lesions or ulcers noted. Psychiatric: Alert and oriented x 3. no evidence of depression, anxiety or apparent distress.
Assessment: Other medical exam for administrative purposes.
Plan: Follow-up visit prn has PCP in NY Hepatitis B titer ordered, will notify pt when results received.
Having a disagreement of correct dx to use. Thanks as always for your help.
HPI: Pt is seen today for her Hep B Titier required for nursing school in NY. She is just visiting over the holidays and will followup with her PCP in NY. She did not have any paper work to be filled out for her school.
Reviewed and discussed 18 ROS check-list and personal-health assessment form with patient. Please see form for details.
PE: Vitals listed. General: The patient is well developed, well nourished, in no acute distress. EYE: Conjuctivae are without erthema. SKIN: Skin is warm and dry without pallor or cyanosis. There are no rashes, lesions or ulcers noted. Psychiatric: Alert and oriented x 3. no evidence of depression, anxiety or apparent distress.
Assessment: Other medical exam for administrative purposes.
Plan: Follow-up visit prn has PCP in NY Hepatitis B titer ordered, will notify pt when results received.
Having a disagreement of correct dx to use. Thanks as always for your help.
