clinical logs

Albany State University CHP (Acct #7157) Case ID #: 1532-20150209-001 Date of Service: 2/9/2015

Student Information - Warren,Alexander Semester:

Spring

Course:

Nurs 6820 Practicum

Preceptor:

BRYANT, Bill Clinical Site:

Southland MD

Setting Type:

Patient Demographics Age:

36 years

Race: White, Non Hispanic

Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 6 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Observation only Reason for Visit: Follow-up (Routine) Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 272/4is not a valid ICD code. CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 1 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Cardiology - Antilipids
Adherence Issues with Medications:
Other Questions About This Case Clinical Notes
Albany State University CHP (Acct #7157) Case ID #: 1532-20150209-002 Date of Service: 2/9/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 72 years Race: White, Non Hispanic Gender: Female Insurance: Medicare Referral: Physician Clinical Information Time with Patient: 7 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Observation only Reason for Visit: Follow-up (Routine) Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 700- CORNS/CALLOSITIES #2 - 496- CHRONIC AIRWAY OBSTRUCTION NEC CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 2 # Prescriptions currently prescribed: 4 # New/Refilled Prescriptions This Visit: 2 Types of New/Refilled Prescriptions This Visit:
Pulmonary - 2-agonist
Pulmonary - Steroid inhalers
Other Questions About This Case Clinical Notes refer to podiatry
Albany State University CHP (Acct #7157) Case ID #: 1532-20150209-003 Date of Service: 2/9/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 64 years Race: Black or African American Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 7 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Observation only Reason for Visit: Follow-up (Routine) Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 250.00- DIABETES UNCOMPL TYPE II #2 - 401.9- UNS HYPERTENSION #3 - 244.9- UNS HYPOTHYROIDISM CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 2 # Prescriptions currently prescribed: 7 # New/Refilled Prescriptions This Visit: 4 Types of New/Refilled Prescriptions This Visit:
Analgesic/Antipyretic - NSAIDS
Cardiology - ACE inhibitors
Endocrinology - Oral glucose lowering agents
Endocrinology - Thyroid
Albany State University CHP (Acct #7157) Case ID #: 1532-20150209-004 Date of Service: 2/9/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 79 years Race: White, Non Hispanic Gender: Male Insurance: Medicare Referral: No referral Clinical Information Time with Patient: 8 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Observation only Reason for Visit: Follow-up (Routine) Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 473.9- UNS SINUSITIS (CHRONIC) CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 3 Types of New/Refilled Prescriptions This Visit:
ENT - Antihistamines
Infectious Diseases - Fluoroquinolones
Miscellaneous - Not covered elsewhere
Albany State University CHP (Acct #7157) Case ID #: 1532-20150209-005 Date of Service: 2/9/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 68 years Race: White, Non Hispanic Gender: Male Insurance: Medicare Referral: No referral Clinical Information Time with Patient: 6 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Less than shared Reason for Visit: Follow-up (Routine) Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 382.9- UNS OTITIS MEDIA CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 3 Types of New/Refilled Prescriptions This Visit:
ENT - Antihistamines
Infectious Diseases - Penicillins
Albany State University CHP (Acct #7157) Case ID #: 1532-20150209-006 Date of Service: 2/9/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 58 years Race: White, Non Hispanic Gender: Male Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 9 minutes Consult with Preceptor: 3 minutes Type of Decision-Making: Low complexity Student Participation: Less than shared Reason for Visit: Follow-up (Routine) Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 401.9- UNS HYPERTENSION #2 - 714.0- RHEUMATOID ARTHRITIS CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 1 # Prescriptions currently prescribed: 3 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Cardiology - Angiotensin II receptor blockers
Albany State University CHP (Acct #7157) Case ID #: 1532-20150209-007 Date of Service: 2/9/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 56 years Race: White, Non Hispanic Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 6 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Less than shared Reason for Visit: Follow-up (Routine) Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 722.6- DEGENERATION IV DISC SITE UNS CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 1 # Prescriptions currently prescribed: 2 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Neurology - Neuromuscular blockers
Albany State University CHP (Acct #7157) Case ID #: 1532-20150209-008 Date of Service: 2/9/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 72 years Race: White, Non Hispanic Gender: Male Insurance: Medicare Referral: No referral Clinical Information Time with Patient: 8 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Observation only Reason for Visit: Follow-up (Routine) Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 041.12- METH RESIST STAF AUREUS NOS CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 1 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Infectious Diseases - Miscellaneous antibiotics
Albany State University CHP (Acct #7157) Case ID #: 1532-20150209-009 Date of Service: 2/9/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 56 years Race: White, Non Hispanic Gender: Female Insurance: Private insurance Referral: No referral Clinical Information Time with Patient: 7 minutes Consult with Preceptor: 1 minutes Type of Decision-Making: Low complexity Student Participation: Observation only Reason for Visit: Follow-up (Routine) Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 780.52- INSOMNIA UNSPECIFIED #2 - 401.9- UNS HYPERTENSION CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 1 # Prescriptions currently prescribed: 2 # New/Refilled Prescriptions This Visit: 2 Types of New/Refilled Prescriptions This Visit:
Albany State University CHP (Acct #7157) Case ID #: 1532-20150209-010 Date of Service: 2/9/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 20 years Race: White, Non Hispanic Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 10 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Shared (50-50) Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 041.12- METH RESIST STAF AUREUS NOS CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Albany State University CHP (Acct #7157) Case ID #: 1532-20150209-011 Date of Service: 2/9/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 8 years Race: White, Non Hispanic Gender: Male Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 6 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Shared (50-50) Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 530.81- ESOPHAGEAL REFLUX CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
GI Agents - H+/K+ ATPase enzyme inhibitors (ie omeprazole)
Albany State University CHP (Acct #7157) Case ID #: 1532-20150210-001 Date of Service: 2/10/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 51 years Race: White, Non Hispanic Gender: Female Insurance: Private insurance Referral: No referral Clinical Information Time with Patient: 8 minutes Consult with Preceptor: 1 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Follow-up (Routine) Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 401.9- UNS HYPERTENSION #2 - 596.51- HYPERTONICITY BLADDER #3 - 496- CHRONIC AIRWAY OBSTRUCTION NEC CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 1 # Prescriptions currently prescribed: 4 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Cardiology - Angiotensin II receptor blockers
Albany State University CHP (Acct #7157) Case ID #: 1532-20150210-002 Date of Service: 2/10/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 53 years Race: White, Non Hispanic Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 8 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Follow-up (Routine) Encounter #: 6-10 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 296.3- MAJOR DEPRESSIVE DISORDER RECURR CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 1 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Psychiatric - Antidepressants
Albany State University CHP (Acct #7157) Case ID #: 1532-20150210-003 Date of Service: 2/10/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 40 years Race: White, Non Hispanic Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 7 minutes Consult with Preceptor: 1 minutes Type of Decision-Making: Low complexity Student Participation: Observation only Reason for Visit: Other Encounter #: 6-10 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 719.46- PAIN IN JOINT LOWER LEG CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 1 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Other Questions About This Case Clinical Notes x ray ordered
Albany State University CHP (Acct #7157) Case ID #: 1532-20150210-004 Date of Service: 2/10/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 27 years Race: White, Non Hispanic Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 7 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 728.85- SPASM MUSCLE CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 2 # New/Refilled Prescriptions This Visit: 3 Types of New/Refilled Prescriptions This Visit:
Analgesic/Antipyretic - Narcotics
Other Questions About This Case Clinical Notes depo shot, voltarin gel
Albany State University CHP (Acct #7157) Case ID #: 1532-20150210-005 Date of Service: 2/10/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 37 years Race: White, Non Hispanic Gender: Male Insurance: Private insurance Referral: No referral Clinical Information Time with Patient: 9 minutes Consult with Preceptor: 1 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 272.4- OTH/UNS HYPERLIPIDEMIA #2 - 607.84- IMPOTENCE ORGANIC ORIGIN CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 2 # New/Refilled Prescriptions This Visit: 2 Types of New/Refilled Prescriptions This Visit:
Urology - Erectile dysfunction medication
Albany State University CHP (Acct #7157) Case ID #: 1532-20150210-006 Date of Service: 2/10/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 52 years Race: White, Non Hispanic Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 7 minutes Consult with Preceptor: 1 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 6-10 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 486- PNEUMONIA ORGANISM UNS #2 - 272.4- OTH/UNS HYPERLIPIDEMIA CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 2 # Prescriptions currently prescribed: 2 # New/Refilled Prescriptions This Visit: 2 Types of New/Refilled Prescriptions This Visit:
Infectious Diseases - Cephalosporins
Infectious Diseases - FluoroquinolonesAdherence Issues with Medications:
Other Questions About This Case Clinical Notes rocephin shot
Albany State University CHP (Acct #7157) Case ID #: 1532-20150210-007 Date of Service: 2/10/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 62 years Race: White, Non Hispanic Gender: Male Insurance: Private insurance Referral: Physician Clinical Information Time with Patient: 6 minutes Consult with Preceptor: 1 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 6-10 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 787.60- FULL INCONTINENCE OF FECES #2 - 788.30- URINARY INCONTINENCE UNSPECIFIED CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 2 # New/Refilled Prescriptions This Visit: 0 Types of New/Refilled Prescriptions This Visit:
Other Questions About This Case Clinical Notes refer to urology and GI
Albany State University CHP (Acct #7157) Case ID #: 1532-20150210-008 Date of Service: 2/10/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 4 years Race: Black or African American Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 7 minutes Consult with Preceptor: 1 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 708.9- UNSPEC URTICARIA CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 0 Types of New/Refilled Prescriptions This Visit:
Other Questions About This Case Clinical Notes well child check
Albany State University CHP (Acct #7157) Case ID #: 1532-20150211-001 Date of Service: 2/11/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 72 years Race: White, Non Hispanic Gender: Female Insurance: Medicare Referral: No referral Clinical Information Time with Patient: 7 minutes Consult with Preceptor: 1 minutes Type of Decision-Making: Low complexity Student Participation: Shared (50-50) Reason for Visit: Follow-up (Routine) Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 401.9- UNS HYPERTENSION CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 2 # Prescriptions currently prescribed: 2 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Cardiology - ACE inhibitors
Albany State University CHP (Acct #7157) Case ID #: 1532-20150211-002 Date of Service: 2/11/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 12 years Race: Black or African American Gender: Male Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 9 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 382.9- UNS OTITIS MEDIA CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 2 Types of New/Refilled Prescriptions This Visit:
Infectious Diseases - Penicillins
Albany State University CHP (Acct #7157) Case ID #: 1532-20150211-003 Date of Service: 2/11/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 40 years Race: White, Non Hispanic Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 7 minutes Consult with Preceptor: Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 6-10 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 728.85- SPASM MUSCLE CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 1 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 2 Types of New/Refilled Prescriptions This Visit:
Analgesic/Antipyretic - Muscle relaxants
Albany State University CHP (Acct #7157) Case ID #: 1532-20150211-004 Date of Service: 2/11/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 55 years Race: Black or African American Gender: Male Insurance: Private insurance Referral: No referral Clinical Information Time with Patient: 8 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 041.12- METH RESIST STAF AUREUS NOS #2 - 401.9- UNS HYPERTENSION CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 2 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Infectious Diseases - Sulfonamides
Albany State University CHP (Acct #7157) Case ID #: 1532-20150211-005 Date of Service: 2/11/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 32 years Race: White, Non Hispanic Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 10 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Follow-up (Routine) Encounter #: 6-10 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 244.9- UNS HYPOTHYROIDISM CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Endocrinology - Thyroid
Albany State University CHP (Acct #7157) Case ID #: 1532-20150211-006 Date of Service: 2/11/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 68 years Race: White, Non Hispanic Gender: Male Insurance: Medicare Referral: No referral Clinical Information Time with Patient: 10 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 6-10 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 496- CHRONIC AIRWAY OBSTRUCTION NEC CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 1 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 2 Types of New/Refilled Prescriptions This Visit:
Pulmonary - 2-agonist
Pulmonary - Steroid inhalers
Albany State University CHP (Acct #7157) Case ID #: 1532-20150211-007 Date of Service: 2/11/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 28 years Race: White, Non Hispanic Gender: Female Insurance: Private insurance Referral: No referral Clinical Information Time with Patient: 8 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 780.52- INSOMNIA UNSPECIFIED CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 1 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Other Questions About This Case Clinical Notes lunesta
Albany State University CHP (Acct #7157) Case ID #: 1532-20150211-008 Date of Service: 2/11/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 8 years Race: White, Non Hispanic Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 9 minutes Consult with Preceptor: 3 minutes Type of Decision-Making: Low complexity Student Participation: Observation only Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 530.81- ESOPHAGEAL REFLUX CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Albany State University CHP (Acct #7157) Case ID #: 1532-20150216-001 Date of Service: 2/16/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 38 years Race: Black or African American Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 7 minutes Consult with Preceptor: 1 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 535.5- UNSPEC GASTRITIS/GASTRODUODENITIS #2 - 401.9- UNS HYPERTENSION CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 1 # Prescriptions currently prescribed: 2 # New/Refilled Prescriptions This Visit: 3 Types of New/Refilled Prescriptions This Visit:
Cardiology - Adrenergic blockers
GI Agents - Nausea meds
Albany State University CHP (Acct #7157) Case ID #: 1532-20150216-002 Date of Service: 2/16/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 67 years Race: Black or African American Gender: Female Insurance: Medicare Referral: Physical Therapist Clinical Information Time with Patient: 6 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 386.58- OTH FORMS COMBIN LABYRINTHINE DYSF CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 0 Types of New/Refilled Prescriptions This Visit:
Other Questions About This Case Clinical Notes meclizine
Albany State University CHP (Acct #7157) Case ID #: 1532-20150216-003 Date of Service: 2/16/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 56 years Race: White, Non Hispanic Gender: Female Insurance: Private insurance Referral: No referral Clinical Information Time with Patient: 6 minutes Consult with Preceptor: 2 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Follow-up (Routine) Encounter #: 6-10 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 401.9- UNS HYPERTENSION #2 - 250.00- DIABETES UNCOMPL TYPE II #3 - 296.3- MAJOR DEPRESSIVE DISORDER RECURR CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 1 # Prescriptions currently prescribed: 3 # New/Refilled Prescriptions This Visit: 4 Types of New/Refilled Prescriptions This Visit:
Cardiology - Calcium channel blockers
Endocrinology - Oral glucose lowering agents
Albany State University CHP (Acct #7157) Case ID #: 1532-20150216-004 Date of Service: 2/16/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 62 years Race: White, Non Hispanic Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 8 minutes Consult with Preceptor: 1 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Follow-up (Routine) Encounter #: 6-10 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 401.9- UNS HYPERTENSION #2 - 296.30- MAJ DEPRESS DIS RECURR EPI UNS CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 2 # New/Refilled Prescriptions This Visit: 2 Types of New/Refilled Prescriptions This Visit:
Cardiology - Calcium channel blockers
Albany State University CHP (Acct #7157) Case ID #: 1532-20150216-005 Date of Service: 2/16/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 7 years Race: White, Non Hispanic Gender: Male Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 5 minutes Consult with Preceptor: 1 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 465.9- ACUTE UPPER RESP INFECTIONS UNS CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Albany State University CHP (Acct #7157) Case ID #: 1532-20150216-006 Date of Service: 2/16/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 58 years Race: White, Non Hispanic Gender: Female Insurance: Private insurance Referral: No referral Clinical Information Time with Patient: 6 minutes Consult with Preceptor: 1 minutes Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Follow-up (Routine) Encounter #: 2-5 Type of HP: Expanded Problem Focused Social Problems Addressed: ICD-9 Diagnosis Codes #1 - 305.1- TOBACCO USE DISORDER CPT Billing Codes #1 - 99213- OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB EXAM;MED DECISION LOW COMPLEX Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 1 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit:
Other Questions About This Case Clinical Notes chantix
Albany State University CHP (Acct #7157) Case ID #: 1532-20150216-007 Date of Service: 2/16/2015 Student Information - Warren,Alexander Semester: Spring Course: Nurs 6820 Practicum Preceptor: BRYANT, Bill Clinical Site: Southland MD Setting Type: Patient Demographics Age: 26 years Race: White, Non Hispanic Gender: Female Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 6 minutes Consult with Preceptor: Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Other Encounter #: 2-5 Type of HP: Expanded Problem Focused S

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