Wiki Subsequent Care - Inpatient Progress Note

[Titali80]

Please help, I appreciate it. Thanks in Advance.
what would be level of care for this inpatient F/U - progress notes?

Pt. No complain
98' 84 14 103/63
Regular
clear
soft Abd. , +BS
A/P
ICH
POD 9 Rehab Today
2. Ecoli uti omnicef
# __________
d/w mother @ bedside

 

[Naveen Rachagolla]

Please help, I appreciate it. Thanks in Advance.
what would be level of care for this inpatient F/U - progress notes?

Pt. No complain
98' 84 14 103/63
Regular
clear
soft Abd. , +BS
A/P
ICH
POD 9 Rehab Today
2. Ecoli uti omnicef
# __________
d/w mother @ bedside

it would be 99231 which is level one, and even i would say thet the physician can even document the note in much better way.

 

[cheermom68]

Very poor documentation, What was clear? What was regular? No interval history. Very slim 99231.

 

[Titali80]

Thank You guys. That's what I said - I would NOT give any of them even 99231. It is embarrassing to say that highly educated people can be so sloppy.

It's fun to put physician education program together for my hospitalist group. Oh my my. I will be bombarded when time comes by few angry physicians. I am up for it.