New Outpatient Consultation
Level Examples
Chief Complaint: Snoring.
History of Present Illness: Mr. SleepyHead is a 36-year-old gentleman self referred for a three-year history of snoring. The patient’s wife does not report that he has any breath-holding but does report that he has chronically loud snoring with grinding of his teeth. He reports occasional daytime somnolence and morning headaches.
ROS: He’s had an increase in his weight over the past 3-4 years by at least 30-40 pounds.
Past Medical History: Denies any previous medical problems.
Past Surgical History: Negative.
Allergies: NKDA.
Medications: None.
Social History: The patient smoked a half pack of cigarettes per day for four years, quit seven years ago. Alcohol is occasional. The patient is married and is a receiver at a paper mill.
CC: _____________________________
HPI: _____________________________
ROS: _____________________________
PMHx, PFHx, PSHx: _____________________________
Level of History: _______________________
Physical Exam
Constitutional: Well developed, well nourished, in no apparent distress.
Head: Atraumatic, normocephalic.
Face: No evidence of significant scars, lesions or asymmetries. Facial nerve is intact and equal bilaterally.
Eyes: Extraocular movements are intact. Pupils are equally reactive to light.
Ears: The tympanic membranes are clear. External auditory canals are clear bilaterally. External-ear without lesions noted.
Nose: No significant external asymmetry. Septum is moderately deviated to the right side with bilateral inferior turbinate hypertrophy. No evidence of polyps or exudate.
Oral Cavity: Good dentition, no lesions. Tongue is symmetric in motion.
Oropharynx: Symmetric elevation of the palate with a positive gag reflex. Floor of mouth is negative for masses or lesions. Normal appearing tonsils. No evidence of lesions or inflammation. Moderate elongation of the palate and base of tongue.
Hypopharynx: No pooling of secretions, no lesion seen in the pyriform sinuses. By mirror exam reveals normal vocal cord mobility and appearance bilaterally.
Neck: Reveals no significant scars, no adenopathy, no masses or thyroid enlargement noted.
How many elements identified by a bullet? __________________________
What level exam is documented? ___________________________________
Medical Decision Making
Impression: Chronic loud snoring, rule out sleep apnea
Recommendation: Overnight sleep study to rule out sleep apnea. Obtain ABGs at appropriate intervals if apnea observed.
Data: ______________
Diagnosis: ______________
Risk: ______________
Complexity of Medical Decision Making: __________________
Put It All Together
History ________________
Exam ________________
Medical Decision Making ________________
Code Documented ________________