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CHIEF COMPLAINT
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PATIENT c/o
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RIGHT LEG
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LEFT LEG
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Additional Patient CC
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SEVERITY OF DISCOMFORT
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LOCATION
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Patient Compliance & Progression Statements
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Patient is significantly concerned due to
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Patient states symptoms started
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ALLEVIATING/ AGGRAVATING FACTORS
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Patient states no discomfort
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Pt states pain in leg is worse when the patient tries to flex his/her lower leg when walking
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Pt states it feels better when resting with his/her leg elevated
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FUNCTIONAL IMPAIRMENT
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Patient is challenged with the following functional impairments
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Ambulation
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STOCKING UTILIZATION/CONSERVATIVE TREATMENT
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Level of Compression Therapy
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CONSERVATIVE THERAPY DETAILS
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OUTCOME OF CONSERVATIVE TREATMENT
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PAST MEDICAL HISTORY
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Drug Allergies
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Active Medications
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Patient has a history of the following
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Past Medical History Freewrite
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Past Surgical History
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Past Surgical History Freewrite
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SOCIAL HISTORY
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Smoking
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If quit, how long ago; If active, PPD for years
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Alcohol
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If quit, how long ago; If active, drinks per day/week or month
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Illicit Drug Use
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If Other, specify and describe
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Females only
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Females only - # of children
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REVIEW OF SYSTEMS/ SUBJECTIVE DATA
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CONSTITUTIONAL SYMPTOMS
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Patient denies
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Other comments
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GENERAL APPEARANCE
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Patient Height
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Patient Weight
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Healthy-appearing
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Well-nourished
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Well-developed
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Level of Distress: (5 Being the Worst, 1 Being the Least Distress)
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Ambulation
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Other comments
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CARDIOVASCULAR
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S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs
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Carotid Arteries
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Pitting Edema
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Right Leg
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Left Leg
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Edema Present In
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Other comments
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GASTROINTESTINAL
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Patient states that diet is maintained with mostly healthy, well-balanced meals.
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Patient has gained weight over the past 6 months.
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Patient has lost weight over the past 6 months.
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Other comments
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MUSCULOSKELETAL
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Joint stability
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Location of Abnormality
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No tenderness to palpation in upper extremities
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Pain/Swelling in
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Back pain on
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Joint pain on
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Muscle cramps on
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Neck pain w/ stiffness on
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Other comments
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INTEGUMENTARY
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Face
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Location of Abnormality
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Other comments
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LOWER EXTREMITIES
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Right Leg S/S
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Left Leg S/S
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CEAP CLASS C 1 2 3 4 5 6 A/S =
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Other comments
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Image of Patient Legs
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Image of Patient Legs
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Image of Patient Legs
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Image of Patient Legs
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NEUROLOGIC
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No Medical History/Injuries
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Awake, Alert, Oriented x3
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Communication ability within normal limits
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Attention and concentration within normal limits
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Patient c/o
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Location of Symptoms
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Other comments
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HEMATOLOGIC/LYMPHATIC
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No Medical History/Injuries
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Patient c/o
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Other comments
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RESPIRATORY
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Even and unlabored
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Clear to auscultation bilaterally
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Abnormal
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Other comments
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COVID-19
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COVID-19 Symptoms Experienced
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DIAGNOSTIC TESTS
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Diagnostic examinations performed
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Results: see attached LEVI report
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Ultrasound Report
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Ultrasound Report
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Additional Diagnostic Report
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Additional Diagnostic Report
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SEVERE FUNCTIONAL INCOMPETENCE OF
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RIGHT GSV
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RIGHT AAGSV
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RIGHT SSV
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LEFT GSV
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LEFT AAGSV
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LEFT SSV
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VCSS
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Venous Clinical Severity Score (VCSS)
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Attribute
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Description of Scoring
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Pain
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Varicose Veins
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Inflammation
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Induration
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Use of Compression Stockings
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Right LE
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Pain
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Varicose Veins
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Venous edema
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Skin pigmentation
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Inflammation
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Induration
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No. of active ulcers
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Active ulceration, duration
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Active ulcer, size
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Compressive therapy
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Left LE
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Pain
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Varicose Veins
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Venous edema
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Skin pigmentation
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Inflammation
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Induration
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No. of active ulcers
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Active ulceration, duration
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Active ulcer, size
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Compressive therapy
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The Venous Disability Score
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RT LE
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LT LE
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CEAP Score
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ASSESSMENT (A):
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Level of visit: new office outpatient visit - 99203
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Chronic Venous Insufficiency 187.2: Dermatitis (eczematous) L30.9 stasis 187.2 Eczema (acute) (chronic) (erythematous) (fissum)
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Patient states currently uses 20-30 mmHg compression stockings with relief
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No indication or visualization of Deep Vein Thrombosis noted via ultrasound assessment
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Indication or visualization of Deep Vein Thrombosis noted via ultrasound assessment
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Patient states currently uses 20-30 mmHg compression stockings without any relief
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Differential Diagnoses
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187.323 – Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity Chronic venous hypertension wi
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187.003- Postthrombotic syndrome without complications of bilateral lower extremity. Postthrombotic syndrome w/o complications o
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L81.0 Postinflammatory hyperpigmentation Hyperpigmentation (darkening) skin, after inflammation; Post-inflammatory hyperpigmenta
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PATIENT DIAGNOSIS
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Patient diagnosis codes
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HPI Note
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PATIENT EDUCATION
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Treatment discussed
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Additional Patient Education
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TREATMENT PLAN
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Treatment Considerations
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UNITS OF TREATMENT
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RFA UNITS RIGHT
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RFA UNITS LEFT
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VARITHENA UNITS RIGHT
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VARITHENA UNITS LEFT
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Billing
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Billing Services
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