Hi - I am currently auditing chart notes(post-audit) for a Cardiology office, would all of these be counted as a diagnosis for MDM summary?
Impressions:
1.) Chest discomfort
2.) Family history of coronary disease, in particular her mother.
3.) Blood pressures elevated at home recently.
4.) Recent herniated disk.
5.) Known history of aortic regurgitation, noted as trivial in echo in 2007.
(this chart note by an MSN,FNP,APRN,BC with physician sign off)
(the Subjective note basically stated pt. has been having hypertension episodes/chest discomfort.)
Recommendations were Myoview Nuclear stress test and Echo ordered, continue current meds, Follow-up after tests completed.)
Thanks for any/all help with this.
Impressions:
1.) Chest discomfort
2.) Family history of coronary disease, in particular her mother.
3.) Blood pressures elevated at home recently.
4.) Recent herniated disk.
5.) Known history of aortic regurgitation, noted as trivial in echo in 2007.
(this chart note by an MSN,FNP,APRN,BC with physician sign off)
(the Subjective note basically stated pt. has been having hypertension episodes/chest discomfort.)
Recommendations were Myoview Nuclear stress test and Echo ordered, continue current meds, Follow-up after tests completed.)
Thanks for any/all help with this.