avrilw
Networker
I need help in coding for suboxone induction. Please see the following chart note. At the end of the note the physician indicated the time involved.
CC: suboxone induction.
History of Present Illness:
Misty presented for suboxone induction. COWS = 18. Last used monday. In CD counselling
Given 4 mg suboxone -- 1 hour later COWS = 15. Given additional 4 mg suboxone -- COWS = 12
Given 4 mg suboxone -- COWS=4. Felt "OK".
Total suboxone given today = 12.
Overall, feeling much better.
Past Medical History:
Reviewed history from 01/31/2014 and no changes required:
Opioid addiction (Hydrocodone)
- Suboxone as of 2/26/14
Melanoma on the left posterior thigh age 26--needs to have regular skin exam.
G5P3SAB1AB1.
Past Surgical History:
Reviewed history from 11/01/2011 and no changes required:
Skin Surgery
R Carpal Tunnel
C Section x 2
Tubal Ligation
Family History:
Reviewed history from 11/01/2011 and no changes required:
Maternal Aunt with Breast CA
Maternal Grandma with COPD, CAD, "cancer"
Paternal side uncertain
Social History:
Reviewed history from 11/01/2011 and no changes required:
Lives with s.o.
Risk Factors:
Tobacco use: current every day smoker
Passive smoke exposure: no
Drug use: yes
Substance: illicit rx
HIV high-risk behavior: no
Caffeine use: Drinks coffee, soft drinks 1-2 times per day. drinks per day
Alcohol use: no
Exercise: yes
Times per week: 1-2 /wk
Type: walking
Seatbelt use: 100 %
Sun Exposure: rarely
Review of Systems
General
See COWS
Vital Signs:
Patient Profile: 35 Years Old Female
Height: 63 inches
Weight: 163.2 pounds
BMI: 29.01
BSA: 1.78
Temp: 97.8 degrees F temporal
Pulse rate: 100 / minute
Pulse rhythm: regular
BP sitting: 122 / 72 (left arm)
Cuff size: regular
Vitals Entered By:
Physical Exam
General:
See COWS
Test Management:
Tests Reviewed:
BUN: 10 01/28/2014
Creatinine: 0.82 01/28/2014
Sodium: 144 01/28/2014
Potassium: 3.3 01/28/2014
Chloride: 111 01/28/2014
HGB: 15.8 01/28/2014
HCT: 45.4 01/28/2014
RBC:
4.99 M/UL (01/28/2014)
WBC: 12.1 01/28/2014
Platelets: 281 01/28/2014
SGOT (AST): 16 01/28/2014
SGPT (ALT): 11 01/28/2014
PROTEIN, TOT: 7.4 01/28/2014
ALBUMIN: 4.4 01/28/2014
ALK PHOS: 43 01/28/2014
BILI TOTAL: 0.5 01/28/2014
Impression & Recommendations:
Problem # 1: OPIOID TYPE DEPENDENCE UNSPECIFIED ABUSE (ICD-304.00)
Suboxone induction performed. Will start 16 mg daily -- 8 mg SL BID.
Destroyed 4 mg of suboxone film that she brough in for induction -- note routed to MA to confirm destruction.
Will f/u friday at 430.
Orders:
Other Procedure (OTHPRO)
Medications Added to Medication List This Visit:
1) Suboxone 8-2 Mg Film (Buprenorphine hcl-naloxone hcl) .... 1 film sl bid
Prescriptions:
SUBOXONE 8-2 MG FILM (BUPRENORPHINE HCL-NALOXONE HCL) 1 film SL BID #4 x 0
Pt was seen multiple times between 0900 and 1415.
CC: suboxone induction.
History of Present Illness:
Misty presented for suboxone induction. COWS = 18. Last used monday. In CD counselling
Given 4 mg suboxone -- 1 hour later COWS = 15. Given additional 4 mg suboxone -- COWS = 12
Given 4 mg suboxone -- COWS=4. Felt "OK".
Total suboxone given today = 12.
Overall, feeling much better.
Past Medical History:
Reviewed history from 01/31/2014 and no changes required:
Opioid addiction (Hydrocodone)
- Suboxone as of 2/26/14
Melanoma on the left posterior thigh age 26--needs to have regular skin exam.
G5P3SAB1AB1.
Past Surgical History:
Reviewed history from 11/01/2011 and no changes required:
Skin Surgery
R Carpal Tunnel
C Section x 2
Tubal Ligation
Family History:
Reviewed history from 11/01/2011 and no changes required:
Maternal Aunt with Breast CA
Maternal Grandma with COPD, CAD, "cancer"
Paternal side uncertain
Social History:
Reviewed history from 11/01/2011 and no changes required:
Lives with s.o.
Risk Factors:
Tobacco use: current every day smoker
Passive smoke exposure: no
Drug use: yes
Substance: illicit rx
HIV high-risk behavior: no
Caffeine use: Drinks coffee, soft drinks 1-2 times per day. drinks per day
Alcohol use: no
Exercise: yes
Times per week: 1-2 /wk
Type: walking
Seatbelt use: 100 %
Sun Exposure: rarely
Review of Systems
General
See COWS
Vital Signs:
Patient Profile: 35 Years Old Female
Height: 63 inches
Weight: 163.2 pounds
BMI: 29.01
BSA: 1.78
Temp: 97.8 degrees F temporal
Pulse rate: 100 / minute
Pulse rhythm: regular
BP sitting: 122 / 72 (left arm)
Cuff size: regular
Vitals Entered By:
Physical Exam
General:
See COWS
Test Management:
Tests Reviewed:
BUN: 10 01/28/2014
Creatinine: 0.82 01/28/2014
Sodium: 144 01/28/2014
Potassium: 3.3 01/28/2014
Chloride: 111 01/28/2014
HGB: 15.8 01/28/2014
HCT: 45.4 01/28/2014
RBC:
4.99 M/UL (01/28/2014)
WBC: 12.1 01/28/2014
Platelets: 281 01/28/2014
SGOT (AST): 16 01/28/2014
SGPT (ALT): 11 01/28/2014
PROTEIN, TOT: 7.4 01/28/2014
ALBUMIN: 4.4 01/28/2014
ALK PHOS: 43 01/28/2014
BILI TOTAL: 0.5 01/28/2014
Impression & Recommendations:
Problem # 1: OPIOID TYPE DEPENDENCE UNSPECIFIED ABUSE (ICD-304.00)
Suboxone induction performed. Will start 16 mg daily -- 8 mg SL BID.
Destroyed 4 mg of suboxone film that she brough in for induction -- note routed to MA to confirm destruction.
Will f/u friday at 430.
Orders:
Other Procedure (OTHPRO)
Medications Added to Medication List This Visit:
1) Suboxone 8-2 Mg Film (Buprenorphine hcl-naloxone hcl) .... 1 film sl bid
Prescriptions:
SUBOXONE 8-2 MG FILM (BUPRENORPHINE HCL-NALOXONE HCL) 1 film SL BID #4 x 0
Pt was seen multiple times between 0900 and 1415.