Objective

BP: 125/87 | Pulse: 92 | Temp: 98.8 °F (37.1 °C) (Oral) | Ht: 5′ 7″ (1.702m) | Wt 195lb 12.8oz (88.8kg)  | SpO2: 99% | BMI: 30.67 kg/m²

General appearance: alert, appears stated age, cooperative and no distress

Head: Normocephalic, without obvious abnormality, atraumatic

Eyes: conjunctivae/corneas clear; PERRL, EOMs intact

Ears: EACs and TMs non-erythematous;  No discharge

Nose: turbinates moist

Throat: lips, mucosa, and tongue normal; teeth and gums normal

Neck: supple, no adenopathy, no JVD, no bruits

Lungs: clear to auscultation bilaterally

Heart: regular rate and rhythm, S1, S2 normal, no murmur, click, rub or gallop

Abd: soft, non-tender, BSX4, no G/R/R

Skin: Skin color, texture, turgor normal; No rashes or lesions

Blood work and findings from his ED visit were reviewed:

CBC was WNL except his hemoglobin was elevated at 17.8g/dl

CMP shows kidney and liver function were WNL. Electrolytes WNL. Glucose elevated (not fasting) at 156mg/dl.

TSH was 3.3mU/L

CT head shows no acute bleed or abnormalities.

EKG shows sinus tachycardia at 110bpm.  No Q waves or ST-T abnormality.

Assessment/Plan

BP is controlled today.  He will continue his HCTZ at 25mg once daily.  No adjustment needed at this time. 

I have referred him to a PCP.  He will check his BP daily and start a log.  He can return to our Urgent Care for any problems or concerns until he sees the PCP.  ED for CP, SOB, or severe headache.  He understands and agrees to these instructions. 

Encounter Medications

Outpatient Encounter Medications as of 10/7/2022:

• HCTZ 25mg – Take one tablet by mouth daily
• Multivitamin plain – Take 1 tablet by mouth daily
• No facility-administered encounter medications on file as of 10/7/2022.

Pre-visit planning was completed via snapshot and review of chart.

I reviewed the patient instructions on the visit summary with the patient/family verbalized to me that they understood what their problem is, what they need to do about it, and why it is important that they follow instructions.

The patient/family voices understanding of all medications. No barriers to adherence were noted. Patient is taking all medications as prescribed and is tolerating well. Plan for follow-up as discussed or as needed if any worsening symptoms or change in condition.

After Visit Summary was given to patient/or sent to MyChart.

Determination of Level of Service (LOS):

We will break this case down by referring to the MDM Elements: 

Number and Complexity of Problems Addressed 

Patient complaint is a follow up from an ED visit. He was diagnosed with HTN and prescribed medication. This would meet the criteria for, “1 stable chronic illness” which is a “low” Level 3. 

Amount and/or Complexity of Data To Be Reviewed and Analyzed 

In this case, the provider did not order any new labs.  The provider reviewed a CBC, CMP, and TSH which was well documented.  Reviewing these three labs meets the criteria for “review of the result(s) of each unique test” which is a “moderate” Level 4. A CT head and EKG were also documented in the note.

Risk of Complications and/or Morbidity or Mortality of Patient Management 

The patient’s BP is currently controlled so the provider documented, “BP is controlled today.  He will continue his HCTZ at 25mg once daily.  No adjustment needed at this time.” This counts towards “prescription drug management” which meets the criteria for “moderate” Level 4 risk. 

2 of the 3 Elements of MDM need to be met when choosing your level of service.  We successfully met Level 4 problems addressed and Level 4 risk.  The correct E/M code is a 99204.