Read the office visit note and abstract the information that is needed for a correct code assignment.
Question Read the office visit note and abstract the information that is needed for a correct code assignment. Assign the correct CPT code ________Chief Complaint: 6-year-old female is brought into the office today by dad for assessment of injuries. HPI: Child was wearing heelies and skating on the sidewalk when she hit a small bump and fell. Immediate pain and swelling to the right wrist. She is unable to move the R wrist. Pain is 10/10. Denies numbness or tingling. Patient is R hand dominant. She also has some scrapes and bruises on both knees. PFSH: NKA, no current meds, no surgical hx, no significant medical or family hx. Patient lives at home with both parents and older brother. VITALS: Ht 3 ft 10 in, Wt 51 lbs, Temp 98.6F WRIST EXAM: 3+/4 edema R wrist; 0/4 edema L wrist; 4/4 pain R wrist; 0/4 pain L wrist; no erythema or induration SKIN: Warm, dry and supple. Contusions and abrasions on both knees. IMAGING: X-ray reveals simple fx styloid process R ulna PLAN: Keep right wrist immobilized and elevated. Ice for 10 minutes every hour. OTC Tylenol for pain, call if something stronger is needed. Keep wounds on knees clean and bandaged, treat with Dermoplast spray at dressing change twice daily. Return to the clinic in 2 days for wrist casting. Call the clinic sooner if any problems. Health Science Science Nursing HI MC165 Share QuestionEmailCopy link Comments (0)
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