Coding Assignment History of Present Illness: Past Family/Social History: Physical Exam: The patient
Coding Assignment History of Present Illness: Past Family/Social History: Physical Exam: The patient is a 27-year-old female here today for a follow up visit for depression and anxiety. This is a known condition and I have been treating the patient for over 1 year. She is not accompanied by anyone else today. She reports some increased additional stress to her previous symptoms. She is having some difficulty at work but reports she feels like she is coping well. She has minimal situation sadness but increased anxiety with stress. Denies any suicidal or homicidal ideations. n/a Review of Systems: no sadness, anxiety, or irritability presently Constitution: appearance WNL, appropriate dress, appears stated agePsych: speech normal rate and tone; thought content; no SI/HI or psychotic symptoms; associations: intact; orientation x3; mood and affect: euthymic and appropriate; Judgment and insight: good Assessment: 1. ______ Depression, stable 2. ______ Anxiety, slightly increased from last visit Plan: 1. Stable on SSRI for depression – continue on same dose 2. Anxiety has increase so we will give Buspar 10 mg BID in addition to SSRI 3. Follow up in 4 weeks 4. Total time spent 15 minutes CPT 99213 Health Science Science Nursing NUR 645 Share QuestionEmailCopy link Comments (0)
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