Attributions

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I saw and evaluated the patient. I personally reviewed overnight events, vitals, labs and medications. I discussed the case with the Nurse Practitioner and agree with the findings and plan as documented with any changes as discussed in my addendum below.


I saw and evaluated the patient. I personally reviewed overnight events, vitals, labs and medications. I discussed the case with the Medical Student and agree with the findings and plan as documented with any changes as discussed in my addendum below.

Documentation Query Responses

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This is a response to a coding query from our documentation team:
- The patient has hypomagnesemia
- The patient is clinically obese with a BMI over 30
- The patient has low albumin

Note Requirements

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Critical Care
Must have 2 parts:
1. Critical illness. 1 or more organ acutely impaired. High prob of iminent life threatening deterioration.
2. Must intervene to prevent deterioration
3. High complexity medical decision making
Min billing time is 30min

Advanced Goals
Face to Face
Name people who were present
Discuss the diagnosis
Min 16 min. Each added 30min is an extra.

Procedure Notes
Must give a codeable diagnosis or signs and symptoms.
Indication for procedure included ascites
Cannot say diagnostic testing or symptom management

Admission Responses

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Got it; we will admit the patient. All of our admitters are busy right now but we will get them in as soon as somebody is available.