Posted and filed under Coding, YouBeTheCoder.

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History of Present Illness (HPI)

Patient is complaining of chest pain which he has been experiencing on and off for two days now. He cannot take a deep breath without getting the pain. When I saw him last month he complained of some nasal and chest congestion but offered no other complaints. He does not have SOB or nausea but has felt more fatigued lately. He had a similar episode last year which was diagnosed as costochondritis. He is a non smoker. He denies any weakness, lightheadedness, fever/ chills, fatigue, dizziness or anxiety.

Allergies: NKDA Current Medications: Levothyroxine 88mcg QAM

Exam

  • Constitutional: BP 130/90, Pulse 86, Resp 18, Pulse Ox 98%. Pt is well groomed. AAAx3
  • Neck: No masses, no crepitus. No cervical adenopathy. Normal thyroid.
  • Respiratory: Normal breath sounds
  • Cardiovascular: RRR S1 S2. Mild tenderness upon palpation.

Medical Decision Making

  • Assessment: Chest pain, unknown etiology
  • Plan: Chest x-ray, cardiac enzymes and EKG.
  • Return after tests done.
  • Electronically signed by Dr. Sample

What were your audit results? Check them with the answers below.

Audit Results

  • HPI Level: EXTENDED
  • ROS Level: EXTENDED
  • PFSH Level: COMPLETE
  • History Level: DETAILED
  • Exam Level: DETAILED
  • Op. Level: EXTENSIVE
  • Complexity Level: MODERATE
  • Risk Level: MODERATE
  • MDM Level: MODERATE
  • CPT Code: 99214