H&P, Assessment, & Note Writing - PowerPoint Presentation

1. H&P, Assessment, & Note Writing

2. Outpatient VisitsNEW PATIENTS99201- 10 minutes3 components: problem focused history, problem focused exam, straightforward medical decision makingProblem is usually self-limited or minor9920220 minutes3 components: expanded problem focused history, expanded problem focused exam, straightforward medical decision makingPresenting problem(s) low to moderate severity

3. 9920330 minutes3 components: detailed history, detailed exam, medical decision making of low complexityPresenting problem(s) of moderate severity9920445 minutes3 components: comprehensive history, comprehensive exam, medical decision of moderate complexityPresenting problem(s) moderate to high severity9920560 minutes3 components: comprehensive history, competent exam, medical decision of high complexityPresenting problem(s) moderate to high severity

4. ESTABLISHED PATIENTS992115 minutesDoes not require presence of the physician our other qualified healthcare professionalPresenting problem(s) minimal9921210 minutesAt least 2/3 components: problem focused history, problem focus exam, straightforward medical decision makingPresenting problem(s) self-limited or minor9921315 minutesAt least 2/3 components: expanded problem focused history, expanded problem focused exam, medical decision making of low complexityPresenting problem(s) low to moderate severity

5. 9921425 minutesAt least 2/3 components: detailed history, detailed exam, medical decision making of moderate complexityPresenting problem(s) moderate to high severity9921540 minutesAt least 2/3 components: coughing to history, comprehensive exam, medical decision making of high complexityPresenting problem(s) moderate to high severity

6. Office: History of PhysicalChief Complaint – completed by medical assistant when rooming the patient (ie. Left thigh soft tissue mass or Right humerus bone lesion)History of present illness – age/gender followed by reason for visit and history about mass/lesion, include history of any personal cancers and their oncologists and treatments done (XRT/chemo/Sx), if in remission for how longPatients with no history of cancer include pain, fevers, chills, numbness/tingling to affected extremity, sudden weight loss/gain, injury/trauma to site, night sweats, does pain keep patient up at night, what pain medications they are currently taking or have triedSoft tissue mass – note any increase/decrease in size

7. Review of SystemsSee HPI above – is NOT acceptable answer!!Need to summarize patient’s complaints such as swelling, LROM, pain

8. Physical ExaminationGeneral: AAO X3, well nourished/well developed; no apparent distressAdd something personal here: husband/dtr/son presentHEENT: NCAT. Head/neck FROMLungs: Breathing comfortably; equal symmetric chest expansionCardiac: we don’t need to address because we don’t assess thisAbdomen: we don’t need to address, however this tumor is in this area – soft, nontender, nondistended, morbidly obeseMass/Tumor: left/right, site, palpable/nonpalpable, mobile/immobile, firm/soft, erythematous/non-erythematous, tender/nontender, describes size in fruits

9. ExtremitiesRange of motion of the joints: full range of motion of all extremities except ... Also include degrees of flexion to effected extremity for baselineMotor strength: WNL to all extremities. B/L UE grips strong/moderate/weak. B/L LE dorsi/pedal flexion strong/moderate/weak. Note comparison of strength by resistanceSensation: grossly intact to all extremities/brisk. Numbness/tingling…Lymph nodes: unremarkable/palpable enlarged sitePulses: B/L +2 radial/pedal pulsesSkin: warm/dry, no lesions/rashes/petechiae/purpura, no clubbing/cyanosis/edema, no other palpable lumps/masses; note any pinning/non-pitting edema hereGait: normal/antalgic/limping/ambulating with walker/ambulating with caneSurgical site: well-healing surgical incision

10. Imaging resultsXR/CT scan/MRI/WBBSBecause Dr. Wittig reviews the actual images, interpretations written in this section must be in accordance with Dr. Wittig’s opinionIf the radiologist report states it is a cyst and Dr. Wittig states it is a lipoma, we document that Dr. Wittig disagrees with radiologist interpretation and finds that the mass is a lipoma based on the findings at the radiologist reports, such as T1/T2 or hypointense/hyperintensePlease include date of when imaging was done as well as site (right thigh). This is an important habit for consistencyPlease include measurements of mass/lesion

11. PathologyThis portion is usually used when the patient comes for their first postoperative visit and pathology is finalizedPlease specify the site, date it was done, and final diagnosis – left posterolateral low-grade liposarcomaIf staging is provided please includeThis portion should also be used for new patients when they have had previous biopsies donePlease specify the type of biopsy such as core needle biopsy, punch biopsy, aspiration cytology (include date when it was done)

12. CulturesNew patients – if they had previous cultures of aspirations or wound cultures; if from other facilities please be sure these reports are obtained and scanned into the system for recordsPostop patients – if cultures were done intraoperatively please follow-up with updated statusGram stain culture, anaerobic culture, fungal culture (may take a few weeks for final result), AFB culture, urine culture

13. LabsIf concern for any kind of infection: CBC with differential, ESR, CRP, UAIf new patient with concern for multiple myeloma in new patient with new lesion and no history of cancer and based on clinical findings: SPEP (serum protein electrophoresis)

14. AssessmentThis section should summarize/condense/organizeThis should include age/gender, reason for visit (if established patient specify frequency of visit), Dr. Wittig’s differential diagnoses (should be noted for most likely to less likely)Est: 64 y.o. gentleman with history of multiple myeloma here today for his 4 month follow up visit with S/P removal of malignant tumor right proximal femur; fixation with long stem cemented hemiarthroplasty. Doing well overall except for some complaints of tolerable pain.New: 26 y.o. woman here today for right knee soft tissue mass causing pain and swelling. After reviewing MRI/XR, this is most likely/probable for PVNS (nodular/diffuse) vs synovial chondromatosis

15. PlanPatients may have more than one presenting problem and these should be numbered in order of most relevant to our specialty to at least relevant to our specialtyIf patient is being referred to another specialist please note physician’s name and specialtyIf reason for visit only need to be monitored please specify that we will continue to observe/monitor until the next follow-upPatient is being scheduled for a procedure please add PCP name/phone numberNote that a mass/lesion can only be definitively diagnosed after a pathology has been done. Until then...Right calf soft tissue massCore needle biopsy performed in the office today in sterile technique. Area was cleansed with alcohol/betadine, site was injected with lidocaine/Marcaine, 7 samples were successfully obtained and placed in formalin, pressure was applied to site, 2X2 gauze/tegaderm dressing was applied to site (this is coded/billed with modifier 25)2. Right knee painDue to mechanical wear and tear, severe DJDPT script given todayEncourage to take Aleve PRN for pain managementOffered steroid injection and patient deferredFollow up: when in with what imaging and reason ( wound check)Discussed in extensive detail: when discussing plan of care with patient with Dr. Wittig please address that all intraoperative/postoperative instructions and care were discussed. If Dr. Wittig informs patients with percentages or any specific complications, this is where it should be documentedTime spent during face to face encounter: be sure that the minutes spent correlates with the code!!