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CHIEF COMPLAINT
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PATIENT c/o
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Additional Patient CC
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Patient states symptoms started
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Functional Impairment
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Impact on Quality of Life
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Conservative Treatments Attempted
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Aggravating Factors
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Alleviating Factors
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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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Patient BMI
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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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CARDIOVASCULAR
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S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs
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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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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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INTEGUMENTARY
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Face
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LOWER EXTREMITIES
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Right Leg
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Left Leg
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Edema Present In
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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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Attention and concentration within normal limits
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Communication ability within normal limits
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Patient c/o
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Location of Symptoms
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HEMATOLOGIC/LYMPHATIC
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Patient c/o
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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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COVID-19
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COVID-19 Symptoms Experienced
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Labs/Testing
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Labs/Testing
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Supporting Documentation
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New Free Draw
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New Free Draw
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New Free Draw
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New Free Draw
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New Free Draw
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New Free Draw
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ASSESSMENT (A):
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Level of visit: new office outpatient visit - 99203
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Level of visit: established outpatient visit - 99213
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PATIENT DIAGNOSIS
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E66. 9 Obesity unspecified is equivalent to Obesity Not Otherwise Specified (NOS)
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R53. 82 Chronic fatigue, unspecified
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R53. Malaise and fatigue
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Z68.3 Body mass index [BMI] 30-39
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Z71. 3 dietary counseling and surveillance
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Additional Diagnosis
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PATIENT EDUCATION
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Additional Patient Education
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Treatment discussed
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TREATMENT PLAN
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Treatment Considerations
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Medical Necessity Justification
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Treatment
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Billing
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Billing Services
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