|
PCP
|
History of Present Illness
|
|
Family History
|
Past Surgical History
• • •
|
|
Smoking status
|
Alcohol
|
|
REVIEW OF SYSTEMS
|
ROS ALL NEGATIVE
|
|
General [+]
• • •
|
Skin [+]
• • •
|
|
Neck [+]
• • •
|
Cardiovascular [+]
• • •
|
|
Respiratory [+]
• • •
|
GI [+]
• • •
|
|
Periph. Vasc. [+]
• • •
|
MSK [+]
• • •
|
|
Neurological [+]
• • •
|
Psychiatric [+]
• • •
|
|
PHYSICAL EXAM
|
|
|
General WNL
|
General Abnormal [+]
|
|
Skin WNL
|
Skin Abnormal [+]
|
|
Neck WNL
|
Neck Abnormal [+]
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal [+]
|
|
Lungs WNL
|
Lungs Abnormal [+]
|
|
Abdomen WNL
|
Abdomen Abnormal [+]
|
|
MSK WNL
|
MSK Abnormal [+]
|
|
Neuro WNL
|
Neuro Abnormal [+]
|
|
Extremities WNL
|
Extrem Abnormal [+]
|
|
Exam Follow Up
• • •
|
Assessment
|
|
General Instructions
• • •
|
General Instruction Comments
|
|
Non Invasive Vascular Lab Studies
• • •
|
Non Invasive Vascular Lab Studies [text]
|
|
Radiology
• • •
|
Radiology [text]
|
|
PROCEDURES
|
|
|
New PT Level 3 detailed/moderate (99203)
|
New PT comprehensive/mod-high (99204)
|
|
Est. PT Level 4 detailed/moderate (99214)
|
Est. PT Level 5 comprehensive/high (99215)
|
|
Global Post Op F/U (99024)
|
|
|
DX's
|
Venous Insufficiency (chronic-peripheral)
|
|
Lymphedema, NEC
|
Pressure Ulcer sacral region, stage 4
|
|
Edema, Generalized
|
Edema, Localized
|
|
Acute Kidney Failure, Other
|
End Stage Renal Disease
|
|
Varicose Veins, LT lower extrem w/inflammation
|
Varicose Veins, RT lower extrem w/inflammation
|
|
Occlusion/Stenosis RT carotid
|
Occlusion/Stenosis LT carotid
|
|
Occlusion/Stenosis Bilateral carotid
|
Sepsis, Unspec organism
|
|
Soft tissue disorder (other) LT lower extrem
|
Soft tissue disorder (other) RT lower extrem
|
|
Soft Tissue Disorder Multiple sites (other)
|
Soft Tissue Disorder (other) Other site
|
