I agree with you.
S: Here with right ankle pain (chief complaint);he twisted it (context). Went to the ER over the weekend.Negative x-ray(mod factor). but very swollen (1 exam element). He states he has broken it in the past(past history).
A&P: Gave him a script for PT for this severe right ankle sprain.
New problem no work up 3 points
So you have PF history, PF exam, Low MDM.
If you could pull 1 ROS out of the history it would be a 3. I debated using very swollen as an ROS but that is more of an exam element in my opinion.
Laura, CPC, CEMC
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