Supporting Documents Case Studies

Transcription

1 Supporting Documents Case Studies ONA Presentation/Case Studies 1

2 CASE STUDY #1 CC: Right Breast Lump History of Present Illness: 41 yr old G3P0 with an LMP of 08/01/2017 who presents today to discuss right breast lump. She first noticed a palpable mass two months ago. Feels like the mass has gotten larger. Not more prominent with menses. Generally non tender. Feels it has been tender once and attributes this to frequently palpating area. Denies skin changes or abnormal nipple discharge. Hasn t noticed any swollen lymph nodes. Her mother was diagnosed with breast cancer at age 50. No other relatives with breast cancer. Her mother has not had genetic testing, nor has she. She has had no prior mammograms. Past Medical/Surgical History/Family history/surgical History: [documented] Vital Signs: [reviewed] Exam: General: well developed, well nourished female, in no acute distress Head: normocephalic and atraumatic Neck: no masses or thyromegaly Chest Wall: No deformities Breasts: Symmetric, no dimpling to skin, R breast with palpable lump approximately 4cm x 4cm, notable, non tender, feels grainy in texture Impression & Recommendations: Problem #1: Breast Mass Orders: mammogram and breast ultrasound with biopsy if indicated Referral completed and faxed to [radiology center] What is the level of medical decision making? A B C Low Complexity Moderate Complexity High Complexity ONA Presentation/Case Studies 2

3 CASE STUDY #2 Chief Complaint: Patient returns for follow up of diabetes, hypertension, hyperlipidemia Subjective: Jennifer is monitoring her blood sugars daily. Usually around 100 in the am fasting. She is watching her diet more closely has cut a lot of red meat out of her diet to help with her cholesterol. Has not experienced any hypoglycemia. Is also monitoring her blood pressure usually about once a week and it runs consistently 120/80. She is taking all medications as prescribed and has missed no doses. She has begun a weekly exercise program. Denies any chest pain, shortness of breath, vision problems or headaches, skin problems. Does foot exams regularly. Objective: Vital Signs: BP 120/80; Pulse: regular; Temp: normal General Appearance: NAD Eyes: PERRLA, EOMI Neck: supple Lungs: CTA CV: RRR, No edema Skin: no cuts on feet, nails normal, clipped straight, Neuro: normal sensation to feet Labs: Hgba1C: 6.4 Assessment/Plan Hypertension stable on meds Diabetes: stable on meds Hyperlipidemia stable on meds Continue current meds return for re check in 6 months What is the established patient level of service? A B ONA Presentation/Case Studies 3

4 CASE STUDY #3 CC: Ovarian cyst History of Present Illness 51yo female referred by neurosurgeon due to a pelvic finding on her MRI performed for back pain. Reports that last week she went to Urgent Care due to back pain. Had an x ray done at that time. She was in so much pain that she went back to the ED. She was sent to a neurosurgeon for possible ruptured discs. She saw the neurosurgeon yesterday who was concerned about a pelvic finding and told she needed to see an OB/GYN right away. MRI report requested during the appointment and received from the referring provider s office. Reviewed with patient: Suspected left adnexum cyst 2.3cm. Non emergent ultrasound suggested. Past Medical History: [reviewed] Family History: [reviewed] Social History: [reviewed] Exam: Vital signs: [reviewed] Impression and Recommendations Problem #1: Other Ovarian Cyst, left side Incidental finding on MRI of lumbar spine; 2.3cm cyst noted on left adnexa US follow up ordered to be completed within the next four weeks. RTC after US for annual exam and results review What new patient level of service does this documentation support? A B C D E ONA Presentation/Case Studies 4

5 CASE STUDY #4 Patient returns for follow up after treadmill/echo Patient noted on previous exam to have atrial fibrillation. This had not been noted before. Patient referred to Dr Smith for evaluation. After evaluation, including a treadmill and echo, atrial fibrillation is confirmed, but there is no physiologic cause evident. Dr Smith wants the patient placed on Coumadin for three weeks in advance of planned cardioversion. Patient is here to begin Coumadin therapy. Physiology of atrial fibrillation discussed with patient and spouse. Risks and benefits of therapy versus non therapy discussed. Patient elects to begin Coumadin. Plan: Coumadin therapy started. 2 mg per day with pro time check in 5 days. Will call patient with results and titrate at that time. Which statement would have supported coding this encounter based on time? A B C D 25 minutes spent with patient discussing treatment plan options 25 minutes spent with the patient, more than half of the encounter spent in counseling 25 minutes spent with the patient, more than half of the encounter spent in counseling and coordination of care 25 minutes spent with the patient, more than half of the encounter spent counseling the patient on treatment plan options ONA Presentation/Case Studies 5

6 CASE STUDY #5 Participants: Patient & provider Chief Complaint: Follow up for medication management HPI: 40 year old patient presents stating she is doing well. She is taking several classes at the community college and is experiencing no problems Current stressors: Patient reports compliance with medications as prescribed. No side effects experienced Depression: patient is currently experiencing no depression Anxiety: anxiety is variable, currently mild symptoms in crowds Sleep: no sleep complaints Mania: none Concentration: stable with current treatment; no distractibility at home or work; concerned she may experience some distractibility with classes Substance Use: no alcohol, nicotine, marijuana; 1 2 servings caffeine per day Medical/Social/Family History: no changes since previous encounter on 12/13/17 Review of Systems: Constitutional: negative Respiratory: negative Neurological: negative Objective: General appearance: NAD, well groomed, well nourished, good eye contact Behavior: cooperative Mood: euthymic Affect: appropriate Thought process: logical, linear and goal directed with appropriate associations Perceptions: No evidence of psychosis Memory: recent and remote WNL Judgement/Insight: good Attention & observed intellectual functioning: intact Alertness & orientation: alert, fully oriented to person, place, time and situation Fund of knowledge: good Musculoskeletal: normal gait and station Medications: ONA Presentation/Case Studies 6

7 Adderall XR 20mg; 2 caps PO q am TraZODone 100mg; 1.5 tabs PO q HS Lexapro 20mg; 1 tab PO q HS Assessment: Bipolar disorder stable Attention Deficit disorder stable Patient continues to make progress toward stated goals Plan: Education Provided: Reinforce instructions for medication use and side effects. Patient verbalized understanding and agreed with plan Medications: Continue all meds; no changes Follow up: 90 days 20 minutes of psychotherapy in addition to E/M service. Supportive and mindfulness used to address social anxiety. I discussed with the patient options for addressing distractibility and social situations. What level of E/M service is supported? A B C Are all requirements of psychotherapy documented? Requirement Time spent specifically in psychotherapy Type of psychotherapy provided Provider s interaction Participants Diagnoses Progress Status ONA Presentation/Case Studies 7