If the prescription and/or the surgery were "considered", then I would count that, assuming the documentation is sufficient.
Example 1: "Treatment options are medication or surgical removal. Pt will await test results."
Example 2: "I recommend laparoscopy with surgical removal of endometriosis. Risks, benefits and alternatives were discussed with patient. Risks include: yadda, yadda, yadda. If patient wishes to avoid surgery at this time, alternative of lupron depot 11.25mg q3 month injections was discussed. Pt will think over options and make final decision after MRI results."
Example 1- I would not count either rx management or decision for surgery. The documentation is too vague.
Example 2 - I would consider both rx management performed and decision for minor surgery with risk.
If you have documentation somewhere in between, you might be able to consider the risk low, but not moderate.
The overarching change for the 2021 outpatient guidelines is that the clinician is receiving more credit for the knowledge and thought process and less for copy/paste old info. However, that thought process needs to be clear on the page in order to credit them.
I really appreciate your feedback and has a follow up question:
Would you consider these for prescription drug management - Moderate risk?
Examples of whether to consider for prescription drug management option for moderate risk:
Assessment/Plan
.... for abdominal pain now resolved. Vaginal discharge on pelvic exam. Abdomen nontender and tolerating PO. Of note, patient is declining blood draw today.
Discussed risks benefits of empiric treatment versus follow up on STD testing results. At this time, patient does not wish to receive empiric treatment and will return for treatment for any positive results, shared decision-making.
HCG negative
UA negative
Impression: Abdominal Pain
Plan:
- Pending:
NuSwab Vaginitis Plus (VG+), Urine Culture
Continue supportive care, instructed on use of OTC medications as needed for symptom relief.
Instructions to follow up with PCP for close monitoring of symptoms given.
Strict RTC precautions for persistent symptoms also given.
Educated on signs and symptoms including new or worsening symptoms that would warrant immediate evaluation in ED.
All questions and concerns answered.
Patient verbalized understanding of and agreement with all instructions and precautions.
Assessment/Plan
Impression: COVID-19 (primary encounter diagnosis)
Plan:
- Nontoxic with no respiratory distress or hypoxia
- Lungs are clear; no indication for imaging at this time and
unlikely to benefit from antibiotics
- Pt is on day #4 of symptoms, improving, and is well-appearing on exam
-
Discussed risks/benefits of antiviral medication (Paxlovid)
- Pt has had 3 doses of Pfizer vaccine (12/1/2021, 3/25/2021, 3/4/2021)
- Per pt, he has no pre-existing medical conditions/medication use
- BMI : 28.9 kg/m²
-
Shared decision-making performed; elected against use of antiviral medication at this time
- Advised scrupulous hand hygiene and self-isolation protocol
- Recommend supportive care (e.g. OTC decongestants, salt-water gargles, NSAIDs, etc) as needed
- Plan of care, appropriate follow-up, and return precautions discussed at length; pt verbalized understanding
A/P: right sided facial abrasion
-
very low risk but offered HIV prophylaxis, patient wants to think about it
-wound cleaned
-covered with layer of bacitracin and non-adhesive gauze
-f/u with supervisor at TCC and PCP
