SBS Ch 15/ IEHR CH2

SBS Ch 15/ IEHR CH2

Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history?
Detailed
This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge. Labs: CBC and urinalysis performed. Allergies: none. Past medical history: genital wart 1986. Past surgical history: wart removed by laser 1986. Social history: no smoking, illicit drugs, or alcohol.
PE: During an expanded problem-focused examination, the HEENT was found to be normal. FHT: A 148, B 146. Heart: normal. Lungs: CTA. Abdomen: gravid 20 cm. Slight tender suprapubic region. Vaginal exam: closed cervix, thick, long; no discharge. Extremities: negative for edema; UA loaded with bacteria and WBC.
Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward).
Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones.
99242
Location: Emergency Room
SUBJECTIVE: A 32-year-old female who presents to the emergency department with chief complaint of increased postoperative swelling. This patient had right neck lymph node biopsy done 3 days ago. Patient has a dressing in place ever since then. For the past 24 hours, she feels like she has increased swelling and she presents now because of it. She denies any accompanying fever, chills, or sweats.
PAST MEDICAL HISTORY: No known drug allergies. Only surgery was wisdom tooth extraction 1 month ago and then the recent lymph node biopsy. Medically, she has a history of depression.
REVIEW OF SYSTEMS: Respiratory: She denies dyspnea.
OBJECTIVE: This is an alert 32-year-old female who appears to be in no acute distress. Temperature is 35.7, pulse 90, respirations 18, blood pressure 144/105, oxygen saturation 99%. HEENT: Conjunctivae and lids normal. Mouth well hydrated. Pharynx normal. Neck is supple. I have removed the dressing. There is a Pen Rose drain in place. The wound seems to be healing well. There is some soft tissue swelling which extends about 3 cm from the wound itself. There is no erythema and no warmth to the area.
ASSESSMENT: Postoperative swelling.
PLAN: I have discussed the case with the ENT surgeon. We have redressed the area. Patient is reassured and will be following up with her doctor tomorrow for drain removal.
99282
History and exam of the normal newborn infant born in a hospital setting.
99460
CHART NOTE
CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks’ duration.
OBJECTIVE: This is a 50-year-old male in apparent good health. His BP is 119/78. Rectal examination showed a Grade I hemorrhoid in the 2 o’clock position approximately 2 cm across. The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted.
ASSESSMENT: Hemorrhoid.
PLAN: Discussed conservative treatment options with the patient and explained surgical option. He wants to try the more conservative approach of stool softeners, warm and sitz baths. I discussed with him the importance of improved bowel habits. He is to return for a recheck in 2 months. The medical decision making was of straightforward complexity.
99212
Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the Intensive Care Unit with acute respiratory distress syndrome
99291, 99292
DIALYSIS PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Gloria Baxter
ATTENDING PHYSICIAN: Ronald Green, MD
This patient is continuing on CAPD. Her weight has fluctuated to some extent dependent on some GI losses. She has not been ultrainfiltrating aggressively, but she has not been eating well either. Over the last day or so she has had problems with hypotension, related to perhaps initially bradycardia and then subsequently to recurrence of atrial fibrillation with a more rapid rate. She did drop her weight to 154, and we have given her some saline boluses through the night. This morning she is reasonably stable. Her weight is 158 pounds. She has no congestive failure and no pain. Her abdomen is soft. Fluid clear. Cultures have remained negative. She had been on Unasyn coverage because of an elevated white count and suspected sepsis but that has not materialized.
The management plan at this time is to discuss a different drug management plan with cardiology to see whether or not she is a candidate for a class III drug in view of the patient’s intolerance to digoxin and/or quinidine. She may well tolerate digoxin at a lower dose, but the problem is it is not effectively blocking her ventricular response.
The other component of her management will be to interrupt the antibiotic and observe her, and then thirdly she will get esophagogastroduodenoscopy today and a CT of her abdomen tomorrow to try to investigate the true core problem that she has. Finally, we are going to increase her Epogen slightly to try to push her hemoglobin up a little faster and try to keep her over 12. This will be a substitute for her hypoalbuminemia and hopefully will maintain her blood pressure and her organ perfusion a little bit better. This illness is still serious. She is not thriving. She is not eating well, and her prognosis at this point is still extremely guarded. Code level II reaffirmed. (MDM is high complexity.)
99233
The physician must consider multiple diagnoses and management options. There is a moderate amount of data to be reviewed and the risk of complications or death is moderate. What is the level of MDM?
Moderate
CHART NOTE
CC: Dizziness
SUBJECTIVE: This 46-year-old female established patient presents today reporting feeling ill yesterday, and she has developed some dizziness. She feels like things stick in her throat and that her throat is “sticky”. She has a past history of hypothyroidism and taking Synthroid 0.125 mg q day. Her last TSH was last year and the level appeared to be normal at 0.49.
OBJECTIVE: The patient appears to be in good health and in good spirits. Her BP is 120/81. Afebrile. HEENT normal. Neck is supple. No palpable masses are noted. No thyromegaly, tenderness, or nodes. TSA is elevated at 9.9.
ASSESSMENT: Hypothyroidism (MDM was low).
PLAN: Increase Synthroid to 0.15 mg q day. Recheck in 2 months.
99213
According to E/M guidelines, a(n) ____ exam encompasses a complete single-specialty exam or a complete multisystem exam
Comprehensive
What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM?
99284
CAPD CYCLER DIALYSIS PROGRESS NOTE LOCATION: Inpatient, Hospital
PATIENT: Mandy Horton
ATTENDING PHYSICIAN: Ronald Green, MD
This patient was reasonably stable overnight. She was evaluated empty. She was in no cardiorespiratory distress. Clear lungs, dullness at the bases. A few crackles but otherwise a somewhat irregular heart rhythm this morning. Echocardiogram pending. Abdomen soft. Exit site okay. She was going to be put on CAPD today. This is being done to facilitate some of her studies as we can work this around them. CT is planned for this morning. The CT will be a critical study since we do have significantly abnormal liver function and the question is what could be possibly going on there. She has an esophagitis consistent with herpes or CMV, and the situation could turn ominous depending on the CT results. We are also doing a calorie count to see whether or not we need to consider supplementing her if everything else works out.
The dialysis plan today will be to use five 2.5-liter exchanges, three of them being 2.5% and two of them 1.5%. (MDM is moderate complexity.)
99232
Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald’s residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward.
99341
A new patient presents to the physician’s office at which time the physician provides a comprehensive history and exam with a high complexity MDM.
99205
The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination?
Detailed
Memorial Hospital is in the process of researching a new facility-wide electronic health record system. The would be responsible for assessing the budgeting process, funding, and for monitoring the monetary aspects of the project?
chief financial officer or CFO
The capturing of data about a patient begins at what point?
When the patient calls for an appointment or arrives at the hospital for care
“A set of standards, services, and policies that enable the secure exchange of health information over the Internet” is known as:
National Health Information Network
A record that contains a person’s health history, allergies, current complaints, past medical and surgical history, and a listing of current medications, but is not considered a legal health record is a/an:
Personal Health Record
The is published by the federal government and includes all actions taken by any government entity on a given date.
Federal Register
The request for advice or opinion from one physician to another physician is this type of service:
Consultation
When a physician performs a preventive care service, the extent of the exam is determined by the:
Age
An established patient is one who has received face-to-face professional services from the physician or another physician of the same specialty in the same group within the past years
3
This entity was founded in 2004 to certify electronic health records
Certification Commission for Health Information Technology (CCHIT)
The is a statement describing the reason for the encounter and is a history element
CC or Chief Complaint
Information that identifies the patient in any way is known as
PHI or protected health information
A professional would most likely hold one of the following positions: cancer registrar, privacy officer, software analyst, compliance officer.
Registered Health Information Administrator (RHIA)
The software allows for the exchange of information among caregivers, insurance companies, employers, and others, when there is a need for information.
EHR or Electronic Health Record