SaritaJP21
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I have chart of established patient with below assessment and plan. Can we consider MDM to high complexity for below example ?As multiple new problems with management are given but these problems may not meet medical necessity for high MDM. Please guide.
Assessment / Plan
Patient with + Influenza A
- Instructed on increase fluids, more rest, and to stay away from work/school/people until 24 hours after last fever.
- Medication below prescribed.
- Patient is allergic to Tamiflu, unable to take
- Return Precaution instructions given to return with worse symptoms, inability to keep fluids down, worsening Shortness of breath, or any other concerns.
1. Influenza-like illness
B34.9: Viral infection, unspecified
R50.9: Fever, unspecified
R10.2: Pelvic and perineal pain
J02.9: Acute pharyngitis, unspecified
5. Influenza due to Influenza A virus
J09.X2: Influenza due to identified novel influenza A virus with other respiratory manifestations
R11.0: Nausea
None recorded.
Assessment / Plan
Patient with + Influenza A
- Instructed on increase fluids, more rest, and to stay away from work/school/people until 24 hours after last fever.
- Medication below prescribed.
- Patient is allergic to Tamiflu, unable to take
- Return Precaution instructions given to return with worse symptoms, inability to keep fluids down, worsening Shortness of breath, or any other concerns.
1. Influenza-like illness
B34.9: Viral infection, unspecified
- RAPID FLU (A+B)
R50.9: Fever, unspecified
- ketorolac 60 mg/2 mL intramuscular solution -
- Inject 2 mL by intramuscular route. Quantity: 2 mL Lot #: ADM905 Route: Intramuscular Site: Deltoid, Left Manufacturer: ALVOGEN INC Exp Date: 01/31/2021 Administered
R10.2: Pelvic and perineal pain
- URINALYSIS, DIPSTICK
- PREGNANCY TEST, URINE
- CULTURE: URINE
- ibuprofen 600 mg tablet -
- Take 1 tablet(s) 3 times a day by oral route as needed for 10 days. Qty: 30 tablet(s) Refills: 0 Pharmacy: WALGREENS DRUG STORE 09709
J02.9: Acute pharyngitis, unspecified
5. Influenza due to Influenza A virus
J09.X2: Influenza due to identified novel influenza A virus with other respiratory manifestations
- codeine 10 mg-guaifenesin 100 mg/5 mL oral liquid -
- Take 10 mL every 4 hours by oral route as needed. Qty: 1 118 mL bottle(s) Refills: 0 Pharmacy: WALGREENS DRUG STORE 09709
- fluticasone propionate 50 mcg/actuation nasal spray,suspension -
- Spray 1 spray(s) every day by intranasal route. Qty: 1 15.8 mL aer w/adap(s) Refills: 0 Pharmacy: WALGREENS DRUG STORE 09709
- Tessalon Perles 100 mg capsule -
- Take 1 capsule(s) 3 times a day by oral route as needed for 10 days. Qty: 30 capsule(s) Refills: 0 Pharmacy: WALGREENS DRUG STORE 09709
R11.0: Nausea
- ondansetron 4 mg disintegrating tablet -
- Take 1 tablet(s) by oral route. Quantity: 1 tablet(s) Lot #: 0d0418014-A Route: Oral Site: Oral Manufacturer: AUROBINDO PHARM Exp Date: 05/31/2021 Administered
- ondansetron 4 mg disintegrating tablet -
- Take 1 tablet(s) every 12 hours by oral route as needed for 10 days. Qty: 20 tablet(s) Refills: 0 Pharmacy: WALGREENS DRUG STORE 09709
- Result:
- Flu: positive - Result Note: Flu type A
- Results:
- Leukocytes: Negative- Nitrite: negative- Urobilinogen: .2- Protein: Negative- pH: 6.0- Blood: Negative- Ketone: Negative- Bilirubin: Negative- Glucose: Negative- Appearance: Clear- Color: Yellow- Specific Gravity: 1.025
- Result:
- HCG: negative
None recorded.