I am going to assume this is a "new patient office visit."
Chief Complaint: allergic rhinitis
HPI: Quality (snots a lot), Assoc (Patient feeling well), Mod Fac (She has been on Claritin for a while), Duration (present for years)
ROS: Const, Eyes, ENMT, CV, GI = 2-9
PFSH: Past Medical History: Unremarkable (Thats if your medicare carrier accepts this term, ours does not). Family History: Hypertension, MI, Breast Cancer, and Colon cancer.Social History: Patient lives with both parents and two brothers. The home is smoke free. Household pets include 2 cats and 2 dogs.
Exam: Const, ENMT, Resp, CV, Skin = 95' Detailed exam
Problem points = 3 (new problem to examiner no additional work up planned)
Level of risk = Moderate (pres. drug mgmt)
Data = None
Moderate Medical Decision Making
I hope this helps, have a great afternoon!
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