note review help

snjberry

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Two questions: 1. do you see URI supported in this documentation? 2. Do you see E&M supported? Below is the note....any help would be appreciated. I don't believe there is sufficient documentation to support URI, HPI is vague, exam says nothing. there is no ROS and CC says here for immunizations nothing about not feeling well

Reason for Appointment
1. Immunization

History of Present Illness
:
Accompanied by:
12 year old female with mild URI symptoms. Good PO, active.

Current Medications
Not-TakingAcyclovir 200 MG/5ML Suspension 10 ml Orally three times a day (tid), Notes: PRN

Past Medical History
Recurrent HSV (nose).

Surgical History
tubes in ears as infant

Social History
Lives with
Allergies
N.K.D.A.

Hospitalization/Major Diagnostic Procedure
No Hospitalization History.

Vital Signs
Temp 97.6, HR 74, BP 112/64, RR 14, Wt 152, Ht 65, BMI 25.29, BMI Percentile 94.04.

Examination
Pediatric Female:
GENERAL: well developed, well nourished, NAD, alert and cooperative. SKIN: no rashes . HEAD: normocephalic . EYES: sclera w/o injection . EARS: TM's normal bilaterally . NOSE: nasal discharge. ORAL CAVITY: moist mucus membranes, tonsils normal . NECK: supple, full range of motion . CHEST: good air exchange bilaterally, no grunting, retractions, pink in room air . HEART: no murmurs, regular rate and rhythm . ABDOMEN: soft without hepatosplenomegaly, without masses, nontender . EXTREMITIES: all move well . NEUROLOGIC EXAM: intact .


Assessments
1. Viral illness - B34.9 (Primary)
2. Encounter for immunization - Z23

Treatment
1. Viral illness
Notes: Symptomatic care.

2. Encounter for immunization
Notes: Immunization as noted.

Immunization
HPV, types 16, 18, bivalent (3 dose), IM : 0.5 mL (Route: Intramuscular)
Procedure Codes
90649 HPV TYP BIVAL 3 DOSE IM
90460 IMADM ANY ROUTE 1ST VAC/TOX
99213 Est PT exam
 
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