Transcription of Documentation Dissection - AAPC
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Documentation Dissection - AAPC
1 Documentation DissectionCOPD Insomnia Back painChief Complaint: Follow-up appt for 62-year-old female COPD coughing more, insomnia follow up, meds working ok. Today she c/o severe back pain no injury recall |1|. Acute : ACUTE ORTHOPEDIC : Thoracic Right |2|; Quality: Sharp Stabbing |3|; Severity: Moderate |4|; Duration: 5 day/s |5|; Timing: Constant; Modifying factors: Worse with cough, deep breath; Associated signs and symptoms: No of chronic conditions |6|:Major Problem List:INSOMNIA using temazepam for sleep and it is working OK overall |6|.RESTLESS LEG SYNDROME |6| |7|.EMPHYSEMA continues to have marked shortness of breath |6| |7|. Using Oxygen continuously at this point |6|.Coughing more than baseline but is trying not to cough due to pain above |6|.PERS HX OF TOBACCO USE CHRONIC OBSTRUCTIVE PULMONARY DISEASE |6|.Objective:Vital Signs: Bp: 118/62, Left Arm, Pulse: 76, Height: 5 3 , Weight: 156 lbs.
Documentation Dissection COPD Insomnia Back pain Chief Complaint: ... of systems, and 2 PFSH, expanded problem focused physical examination was performed documenting four organ systems or body areas with notation of elements for each system area selected. The treatment plan details medication maintenance, and an
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