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1. You have been asked to audit a Pediatric Group Medical Records. In addition to verifying the appropriate E & M code assigned, you are tasked with ensuring that all relevant documentation is present in the record. 

Use the scenario and checklist that follow to determine if all the relevant documentation is present in the record including discharge status.

Verify the E & M code assigned. If the code is incorrect, select the appropriate code. Defend your selection whether you determine it is correct or incorrect.

Office note; 7/15/19

Timothy is a 9 month old male who presents today with bilateral ear- aches Timothy’s mother states that the child has been crying and pulling at his ears for the last two days she has also noticed a mild fever. Otoscopic examination revealed bulging tympanic membrane indicative of fluid build up.

 CPT code assignment for visit: 99202 

Birth history

10/9/2018 Timothy had an uneventful, full term vaginal birth. Uncomplicated pregnancy, natural childbirth. No forceps used in delivery. APGAR   score at Birth 8, APGAR 10.

Personal, social, and family history

11/10/2018  Second child, one older sister who is four years old. Parents are married. Non-smoking environment. No pets in the home. Will attend daycare after mother’s maternity leave and in 3 months. Circumcised prior to discharge  At Birth.

Nutritional history

11/10/2018 Timothy is breastfed initially.

12/13 /2018 breastfeeding continues. 

2/16/19 breastfeeding continues. 

4/18/19 has been introduced into diet, rice. 

7/15/19 Infant eat rice and oatmeal cereal, variety of fruits. No restrictions noted to new foods.

 Office note: 11/10/2018

 well child visit  No problems. Child thriving. Growth appropriate.

Office note:  12/13/2018

 well child visit. No problems. Growth appetite. First set vaccines administered . 

 Office note: 2/16/2019

 well-child visit. No problems. Grow appropriate.  Developmental Milestones met. Second set of vaccines administered.

 Office note: 4/18/2019 

 well-child visit. No problems. Gross  appropriate. Developmental Milestones met  Third set of vaccines administrated.

 Medications

7/15/2019 Amoxicillin BID  for 10 days.

Checklist

_Office note – well child or medical issue

_Birth history

_Nutritional history

_Personal, social and family History

_Growth and development record

_Immunization

_Medication 

_ Discharge status
SCIENCE
HEALTH SCIENCE
NURSING

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