is this 99285 or 99284 ? see chart below Thanks! (ED visit 11 y/o )

kviolet

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PES PA/Attending Brief/FT Note [Charted Location: BXXX-BXXX-01] [Authored: 26-Dec-2015 20:31] - for Visit: 000058577 690, Complete, Entered, Signed in Full, General

Provider Information:
Pre-Assessment Chief Complaint:
· Chief Complaint/Subjective petecihiae all over body since yesterday

ED Provider Medical Screening Comments:
No Comment at 26-Dec-2015 18:39.


Time Medical Screening Exam Initiated:
Time: 18:39 Date: 26-Dec-2015.
Provider Information:
· Time Seen by Me (Military Time): 18:39 Date: 26-Dec-2015.
· I have read and reviewed the RN triage assessment, vital signs, pain assessment, allergies, POC test data, and outpatient medications.
· History From: Patient and Family.


Known Health Issues:
Past Surg Hx:
H/O circumcision: Onset Date: May 2005, Entered Date:
Acute Dx:
Immune thrombocytopenic purpura: Entered Date:
Chronic Dx:
Dermatitis: Entered Date:


Add or Update Provider by clicking below:
· Primary Care Provider:

Pain Assessments:
Pain Scale:
Faces Pain Scale - Revised...

Assessment & Plan:
Provider Note:
11 yo M
pmhx ITP s/p recent admission on 12/14 for thrombocytopenia
presents to ED for petechiae x 1 day
pt states that has had petechial rash x 1 day
has no complaint, no headache no fevers
reports has had back pain on and off x months but this is not new today

Denies nausea, vomiting
Denies fevers, chills, night sweats, weight loss
Denies chest pain, shortness of breath, palpitations
Denies abdominal pain, diarrhea, constipation, melena, bright red blood per rectum
Denies dysuria, hematuria, flank pain

BP 109/62 HR 87 R 22 T 0.0 (37.4) Wt (22-Dec-2015) 47.1kg (103.8lbs) Ht (22-Dec-2015) 139.0cm (4'6") BMI 24.4
nad, well appearing, playing on his tablet device
anicteric conj pink
op clear no stridor trimus or erythema
tm's clear
no mastoid ttp
rrr
cta bilatearlly
belly soft and nontneder
ext wwp cap refill brisk
motor 5/5 and silt x 4 ext
gait nml cn 2-12 intact
no midline c/t/l/s ttp
diffuse petechiae on arms legs face trunk no purpura
neck supple no meningismus neg kerngi brudz

plts 4

a/p likely acute flare of ITP, doubt sepsis as pt afeb and well apperaing
d/w heme fellow leonore who knows patient well and recommends 1gm/kg IVIG
as this is a lomg infusion and pt has bed, d/w floor team who will conduct infusion in house.

Diagnosis:
ED Diagnosis:
Immune thrombocytopenic purpura (D69.3).

Patient Instructions:
* Patient Currently Takes Medications as of 26-Dec-2015 19:00 documented in Prescription Writer
Outpatient Medications:
* Patient Currently Takes Medications as of 26-Dec-2015 19:00 documented in Prescription Writer
predniSONE 5 mg oral tablet: Hx, Status: Active, 1 tab(s) orally every other day -Indication: ITP
Zantac 75 oral tablet: Hx, Status: Active, 1 tab(s) orally once a day -Indication: GI Inflammation/Acid Reduction

Medication Reconciliation:
* I have made a good faith effort to review this patient’s home medications. In addition, I have reviewed all medications given during this visit and all new prescriptions.

I-STOP –> Prescription Monitoring Program Attestation (PMP):
3. I am not entering a prescription for any schedule II, III or IV drugs to this patient.

Procedures::
Procedures were:
Procedures were not performed Please Note: This information will be given to the patient.


NYP I-STOP:

Level of Care:
Disposition:
Condition: Stable.

Disposition: Admit.

Admit Service: General Medicine Admit Time: 20:32.

Inpatient Provider Endorsement Nisha.

Inpatient Provider Pager # 85437.

Level of Care:
Level of Care V.

Complete:
· Note completed by attending: Yes
 
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