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Help with subsequent visit note

  1. Default Help with subsequent visit note
    Medical Coding Books
    I work for a group of hospitalists and am having an issue with the following note. To me it looks as if there is a minimal exam at best. I see the notation for Heart: RSR, however I do not see much more than that. I would appreciate someone looking at this a letting me know what level you get, and how you reached that decision.

    Impression:
    -
    r/o UTI - mixed culture
    Hypokalemia - repleted
    Adrenal Insufficiancy on chronic steroids
    PUD
    Fibromyalgia
    Depression/Anxiety/panic attacks
    Celiac Sprue
    Embolic CVA - anticoagulated on Coumadin 1999
    Supratheraputic INR - improving
    Hx of recurrent vertigo

    Plan:
    -
    place TEDS
    consult ATC
    hold coumadin until INR < 3

    Note:
    -
    Chart reviewed
    Pt feels weakness has improved
    Orthostatic this AM - has been followed by ATC for the same
    Appetite is returning
    Afebrile since admission

    Vital Signs
    Date Time Temp Pulse Resp B/P O2 Delivery
    12/29/10 10:28 Room Air
    12/29/10 07:30 96.9 103 20 94/51
    12/29/10 02:30
    12/29/10 0723
    Blood Pressure Assessment 94/51 Left Upper Arm Standing
    Blood Pressure Assessment 113/62 Left Upper Arm Sitting
    Blood Pressure Assessment 159/77 Left Upper Arm Supine
    Blood Pressure Assessment 136/83 Left Upper Arm Supine

    Percent Meal Consumed 25% - 75% House

    Lungs: clear
    Heart: RSR

    Probable viral syndrome - no evidence of UTI. No elevated WBCs or fever. Neg nitrate and Neg esterase
    Unable to recuture urine - on antibiotics x 3 days
    C/o post nasal drip and nasal congestion on admission - resolving.

    Postural hypotension noted - will consult ATC who has been managing as an out pt






    Ceftriaxone 50mls @100 mls/hr
    Sodium 1 gm/ Q24H/IV
    Dextrose
    Anyhydrous DAY # 3


    Pre-admission Medications:
    -
    Cortef 10 Mg PO DAILY
    Midodrine Hcl 10 Mg PO DAILY

    Coumadin 4 Mg PO TAKE AS DIRECTED
    Coumadin 6 Mg PO TAKE mon and thurs
    Klor-Con 20 Meq PO DAILY
    Clonidine 0.1 Mg PO DAILY
    Omega 3-6-9 1200 Mg PO DAILY
    Niacin 500 Mg Capsule PO DAILY

    Tramadol Hcl 1 Tab PO Q4-6H PRN severe back pain
    Ultram 100 Mg PO Q4-6H
    Gabapentin 100 Mg PO TID

    Prilosec Otc 20 Mg PO BID

    Amitriptyline 100 mg PO HS
    Sertraline Hcl 75 Mg PO DAILY
    Fexofenadine Hcl (Allegra) 60 Mg Tablet PO BID
    Flonase 0.05% Nasal Spray 2 Spray NASAL DAILY

    Probiotic Formula Capsule 2 Each PO BID
    Garlic 400 Mg PO DAILY
    Multivitamin Tablet 1 Tab PO DAILY
    Vitamin C 1000 Mg PO DAILY
    Calcium + D 2 Udtab PO DAILY



    Clinical Data:
    -

    Hemoglobin 12.0 gm/dL 12/29/10 0700
    Hematocrit 37.3 % 12/29/10 0700
    White Blood Count 5.8 K/mm3 12/29/10 0700
    Platelet Count 204 K/mm3 12/29/10 0700

    Sodium Level 138 mmol/L 12/29/10 0700
    Potassium Level 3.6 mmol/L 12/29/10 0700
    Chloride Level 106 mmol/L 12/29/10 0700
    Carbon Dioxide Level 24.7 mmol/L 12/29/10 0700
    Blood Urea Nitrogen 10 mg/dL 12/29/10 0700
    Creatinine 0.81 mg/dL 12/29/10 0700
    Estimat Glomerular Filtration Rate > 60 12/29/10 0700
    Fasting Glucose 91 mg/dL 12/29/10 0700
    Calcium Level 8.5 mg/dL L 12/29/10 0700
    Total Bilirubin 0.7 mg/dL 12/29/10 0700
    Aspartate Amino Transf (AST/SGOT) 28 IU/L 12/29/10 0700
    Alanine Aminotransferase (ALT/SGPT) 20 IU/L 12/29/10 0700
    Total Protein 5.9 g/dL L 12/29/10 0700
    Albumin 3.1 gm/dL L 12/29/10 0700
    Globulin 2.8 gm/dL 12/29/10 0700
    Alkaline Phosphatase 69 U/L 12/29/10 0700

    Prothromb Time International Ratio 3.16 INR 12/29/10 0700

  2. #2
    Location
    Hartford, CT
    Posts
    723
    Default
    I see three, 1) constitutional (Temp 96.9, Pulse 103, Resp 20, BP 94/51) 2) Respiratory (lungs clear) 3) cardiovascular (Heart regular sinus rhythm). This would make it expanded problem focused by 95 guidelines and problem focused by 97.

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