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Money is often left on the table as coders and billers struggle to capture ALL necessary medical chart components that correspond to full reimbursement for services rendered.

Review the following medical documentation to determine how accurate the medical claim is below. When you have completed your review, click on the “show me” button to see how well you’ve done.

6/19/2013

Nurse Note: Patient brought in by mom because he stepped on a nail.

HPI:15-year-old male brought in by mom with foreign body in his foot. The occurrence was today at 11 am. Location: RT foot. Degree of pain is moderate. Degree of dysfunction: Pain with weight bearing. Stepped on a rusty nail while walking bare foot in the garage and went approximately 0.5 inches into the RT foot.

ROS:
Constitutional: Fever
Neurologic: Negative
Allergies: NKA

PAST Medical/Family/Social History
Medical History: Vaccinations reviewed, Tetanus is not up to date.

PHYSICAL EXAMINATION:
General Appearance: Mild Distress
Heart: Regular rate and rhythm, no extra heart sounds
Respiratory: Lungs Clear to auscultation bilaterally
Extremity: Normal range of motion. Normal tone. Puncture wound sole of the foot at the first toe, swelling and redness to anterior foot, there is a small rusty nail embedded in the subcutaneous tissue.
FROM of ankle and toes.

PLAN:
Td 0.5ml
Rx: Keflex 500 mg, Ibuprofen 600 mg

DIAGNOSIS:
Foreign body in foot

PROCEDURE:
Verbal consent obtained. Area anesthetized with Lidocaine 2% without epinephrine, 2 ml used. Foreign body was removed by making a small incision and removing with forceps. Bleeding controlled, steri-strips and dressing applied. Patient tolerated procedure well.

J Smith, MD

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