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hpi, Exam, mdm question

  1. #1
    Default hpi, Exam, mdm question
    Medical Coding Books
    Using the 1995 guidelines, what level of exam do you get.

    51 yr. old female with hx of psychosis & s/p repair of an incarcerated hernia 8 mons. prior

    cc -presently constipated. Takes mineral oil 4 tablsp.
    Appetite good
    Allergies: PCN, erythromycin.
    Meds. Klonipin, seroquel, advair, albuterol, calcium.

    Ex: B/P110/70, p-80, resp., 16 ht.5.5, wt 122. A&O x3
    Heart – S1+S2, no murmurs
    Lungs – clear
    Abdomen –R hernia repair noted, BS +, abdomen flat.

    PLAN: Constipation – Lactulose - once daily/ prn,
    and instructed to increase fluid intake

    Thank You in advance

  2. #2

    =) Erica

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