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Business Negocio note Nota illness enfermedad Risk Riesgo Review revisión Required Necesario Sample Note Nota de muestra
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H o s p i t a l P r o g r e s s N o t e 2 out of 3 Key Components Required Patient: E/M 99231 99232 99233 Date: Hx PF EPF Det Exam PF EPF Det MDM SF/Low Mod High Time 15 25 35 ROS (-) Positive Findings Constitutional Eyes ENT Cardiovascular CC: Interval History: y Respiratory r Gastrointestinal o Skin t Musculoskeletal s Psychiatric i Genitourinary Endocrine H Neurological Hem/Lymphatic PF: 1 -3 HPI elements or status of 1 - 3 EPF: 1 - 3 HPI elements or status of 1 - 3 Det: ≥ 4 HPI elements or status of 3 problems, problems (No ROS required) (99231) problems plus 1 ROS (99232) 2 - 9 ROS NO PFSH required (99233) Allergic/Immun Constitutional: NAD, conversant, pleasant BP HR RR T (appearance) Exam Findings Data Reviewed (three vital signs) Data Reviewed Eyes: Anicteric sclerae, moist conjunctiva, no lid-lag PERRLA fundi clear, disc margins sharp l ENMT: NC/AT a Neck: Supple, FROM no masses or JVD c Lungs: CTA i CV: RRR, no MRGs s ABD: Soft, NABS, no masses y Review and/or order clinical lab tests Review and/or order radiology tests oropharynx clear no erythema/exudate Skin: Normal temperature, tone, texture and turgor no induration or subcutaneous nodules no rash, lesions or ulcers m Sa and percussion no carotid bruits normal respiratory effort normal PMI no peripheral edema no hernias e pl h no HSM P Ext: No digital cyanosis/ischemia Pedal and femoral pulses intact and symmetrical Normal gait and station Psych: A O X 3 appropriate affect Neuro: CNs II - XII intact PF: 1 - 5 bullets 3 1 2 1 1..
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