medical billing and coding
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LOCATION: Nursing
Home
PATIENT: Thomas Weiss
PHYSICIAN: Frank Gaul, M.D.
HISTORY: Mr. Weiss is seen for a routine visit for Alzheimer’s.There is no code in place. The chart is reviewed along with thenursing notes. Advanced directives are in place. The graphic chartis also reviewed. The patient is experiencing no fevers, chills,chest pain or shortness of breath. Nurse states patient continuesto be frequently delusional.
EXAMINATION: This well-developed, well-nourished gentleman issitting without distress.
HEENT—normocephalic and atraumatic. Neck is supple. Lungs areclear to auscultation. Extremities show little to no edema.
IMPRESSION:
1. Alzheimer dementia
2. Atypical psychosis with delusions
PLAN:
1. As the patient is otherwise clinically stable; the rest ofthe treatment is without change.
