Wiki What level history do you get? Consult code

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njohnson0476

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Chief complaint: Lower Back Pain

History: The patient is a 56-year old gentleman, who has been having gradually increasing problems with lower back pain episodes, occasionally with sciatic pain in his right leg. the most recent episode resulted in marked back pain, spasm, and inabilty to stand up straigh; it occurred yesterday and resulted in his hospitalization.

The patient indicates currently that his lower back is substantially improved with inital hosptial treatment. There are no neurologic complaints, and no bowel or bladder dysfuntion.

Past Medical history:
1) hypertension
2) hypercholesterolemia
3) osteoarthritis

Past Surgical history:
1) knee surgery
2) Tonsillectomy

Allergies: none known

Medications: There are 4 listed

Family history: He has an aunt with back disease.

Social history: Nonsmoker.

Review of systems: Otherwise in good health.
 
ROS limits you to Detailed

I agree with Laura. The ROS limits you to Detailed history. "Otherwise in good health" does not count at all.

I counted "no neurologic complaints, and no bowel or bladder dysfuntion." as ROS.

F Tessa Bartels, CPC, CEMC
 
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