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? Rov and sov

  1. #1
    Question ? Rov and sov
    Exam Training Packages
    THE DOCTOR WANTS ME TO CHARGE FOR THE ROV AND FOR AN SOV. I DON'T THINK THERE IS ENOUGH IN THIS NOTE TO DO THAT. WOULD LIKE ANOTHER OPINION PLEASE.

    Reason for Visit/ Chief Complaint
    16 yr rov.
    chaperone declined.
    Accompanied by Parents
    Parental concerns? Y
    behavorial issues- ODD. doesn't take responsibility for anything per mom. p's have thrown him out of the house for his behavior and arguing. fa thinks he is much better when he is on the meds.
    not taking concerta- refuses.p's having difficulty coping with him.
    drinking and urinating a lot in past year- gets worse.


    Vital Signs
    AGE 16y6.7m
    BLOOD PRESSURE 114/68 R Arm
    BLOOD PRESSURE (%) 29/51
    HEIGHT 72.75 in
    HEIGHT (%) 92
    WEIGHT 171.2 lb
    WEIGHT (%) 87
    BMI 22.8
    BMI (%) 72

    Interval History
    Illness/Injury since last vist? N
    Specialty appointment since last visit? N
    Hospitalization, Sugery, ER, Urgent visit since last visit? N

    Family History
    Family consists of: Mother; Father; Siblings
    bro and sister
    Infectious Diseases Y
    legionnaires disease at 52. died of lung disease at 81. mgf
    Asthma N
    Deafness N
    Eye N
    Cardiac Y
    mgf- valve replacement.
    GI N
    GU N
    Endocrine Y
    pgm,mgf-dm
    Psychiatric N
    Mental Retardation/ Developmental Delay N
    Neurological Y
    mgm-stroke- died of stroke at 72.
    JRA Y
    mom RA, pgf also
    Skin N
    Congenital N
    Cancer N
    Allergies N
    Other Y
    pgf-copd
    Social History
    Household changes?
    moved in billerica. may 09.
    Smokers in environment? Y
    fa
    Pets in environment? Y
    2 dogs
    Firearms in environment? Y
    fa goes to gun range.locked
    TB Risk Status? Low
    Violence in home? N
    Financial instability? N
    Education Attends school; Has career plans
    mechanic
    Substances
    Use tobacco? Current
    5 / day
    Use alcohol? Current
    occ beer few few times a month.
    Use drugs? Current
    blunt mj weekends.
    Sexual History
    Age first sexual activity
    16
    Lifetime number of sexual partners
    1
    Partners opposite sex? Y
    Partners same sex? N
    Contraception used? Y
    condoms
    STDs? No

    Education and Activities
    Grade Level 11th Grade
    School Type Public
    Name of School
    billerica hs.
    School Performance Fair
    Weaknesses
    chemistry- failed
    refused summer school.
    Sports Yes
    baseball- town league
    Music Yes
    guitar, bass.
    Dance No
    Clubs No
    Drama No
    Hobbies Yes
    bikes
    Diet
    Rate eating habits Poor
    Food groups? Meats; Vegetables; Fruits; Grains; Dairy
    Other liquids? Milk; Juice; Water; Soda
    discussed.
    Comments
    junk food
    Sleep
    Sleeps through night? Y
    Sleep concerns? N

    Safety
    The following safety items were discussed (age approp.): helmet for bicycle-rollerblades-skiing; seat belts; driving

    Physical Exam
    General Appearance
    WDWN, NAD
    Skin
    No cyanosis, rash, abnl pigmented lesions, striae, intertrigo, hirsutism
    Head
    Normocephalic, atraumatic, no facial dysmorphism
    Eyes
    PERRL, red reflex present, EOM normal, corneal light reflex normal
    Ears
    NL canals, TMs clear with normal landmarks
    Nose
    NL shape, no discharge
    Mouth
    NL tongue, mucosa, dentition
    Throat
    NL tonsils. No petechiae, exudate
    Neck
    Supple, no adenopathy or masses, no thyromegaly
    Heart
    RRR, no murmur, S1 & S2
    Lungs
    Clear to auscultation, no rales or wheezes
    Abdomen
    Soft, non-tender, no masses. Liver/spleen not enlarged. NL bowel sounds.
    External Genitalia
    NL external genitalia. No hernia. No discharge
    Breast
    No masses or discharge bilaterally
    Extremity
    No deformity with full range of motion, no poly/syndactyly, no edema, no genu varum/valgus
    Neurological
    Age appropriate reflexes present. DTRs symmetric/non focal
    Gait
    NL gait, without limp, in-toeing
    Back
    Flexible without scoliosis
    Assessment Routine well child care EXCEPT:
    adhd,behavioral problems. ODD.
    polydipsia, polyuria
    crafft=u-2

    Plan
    Plan
    u/a and ua for chlam and gc
    blood sugar.
    MH list given= recommended family therapy.
    discussed with p's and pt
    Discussed diet, activity, screen time and counselled about weight management. 5/2/1/0.
    recommended going back on the concerta- he thinks he will take it again.will decide soon.
    Next appointment
    1 y
    if starts concerta will rto for f/u as usual.
    Allergies
    NKA

    I THOUGHT WE COULDN'T USE PARTS OF THE ROV AS PART OF THE SOV SINCE THAT WOULD BE DOUBLE-DIPPING. ANY THOUGHTS?? THANKS

  2. #2
    Default
    What is an ROV and SOV?

  3. #3
    Default
    routine office visit and sick office visit

  4. #4
    Default
    behavorial issues- ODD. doesn't take responsibility for anything per mom. p's have thrown him out of the house for his behavior and arguing. fa thinks he is much better when he is on the meds.
    not taking concerta- refuses.p's having difficulty coping with him.
    drinking and urinating a lot in past year- gets worse.

    recommended going back on the concerta- he thinks he will take it again.will decide soon

    Based on this info alone you could support a 99213 in addition to your well care visit.

    I will also state I am a bit confused by some of the abbreviations used in this note. If you are using non standard abbreviations make sure you have a master list explaining what they are on file in case of outside audit.

    Laura, CPC, CPMA, CEMC

  5. #5
    Default
    Which abbreviations are unusual?? I'd like to have them checked incase of audit. I'm used to these doctors style so i didn't realize the abbreviations they are using aren't common. Thanks alot:d

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