Premise Quick Consult Notes

Flowchart for Epic visits

1. Write NOTE
2. WRAP-UP
   • "Global" REVIEW
   • Reconcile outside information – if any (look for orange bar)
   • LEVEL of SERVICE
           
     • For in-person visits (except annual exams) - use the wizard
           
     • For annual physical exams - enter manually (chart available here)
           
     • For phone visits - use time-based
           
     • Note that the last digit = the level
3. PLAN
   • Select one or more VISIT DIAGNOSES
           
     • For nutrition consults, choose: Nutrition Counseling ICD-10: Z71.3
           
     • For almost all other phone visits, choose: Encounter to Discuss Test Results ICD-10: Z71.2
4. ROOMING
   • Confirm patient entered data for HISTORY– if any
   • Reconcile outside information – if any (look for orange bar)
5. Sign

CPT Codes for Counseling

Codes 99401–99404 are used to report counseling addressing “such issues as family problems, diet and exercise, substance use, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results available at the time of the encounter."

Annual Routine Physical Exam - CPT Codes

Cholesterol/Lipid Panel Follow-Up

Hyperlipidemia is elevated LDL OR triglycerides

Mixed Hyperlipidemia is elevated LDL AND triglycerides

Hypercholesterolemia is elevated LDL without elevated triglycerides

Code low HDL as E78.6: Lipoprotein deficiency

NOTE

Pt presents to clinic for lipid panel lab review.

- - or - -

Pt with controlled HLD on statin therapy presents to clinic for lipid panel lab review.

HDL: ***
LDL: *** (elevated)
TriG: ***
BG: ***

Advised lifestyle changes including exercise and healthy diet. Discussed adding more foods like olive oil, avocados, walnuts, oatmeal, apples, oranges, salmon, and tofu. Recommended limiting foods like egg yolks, animal products, full-fat dairy, processed snacks, alcohol, simple carbs/starches, and sugars. Instructed to follow up in clinic in 2-3 months for cardio check to determine if improvement has occurred with lifestyle changes.

Advised to continue healthy lifestyle choices, including exercise and healthy diet. Discussed continuing to eat foods like olive oil, avocados, walnuts, oatmeal, apples, oranges, salmon, and tofu. Recommended limiting foods like egg yolks, animal products, full-fat dairy, processed snacks, alcohol, simple carbs/starches, and sugars.

No other risk factors for cardiovascular disease:

• Denies HTN
• Denies DM
• Not a smoker

Nutrition Counseling

NOTE

Discussed following healthy lifestyle by engaging in regular exercise and following healthy diet. Explained the difference between trans-fat, saturated fat, and healthy fats. Gave examples of specific foods for each category. Discussed complex carbs vs. refined carbs, and how these can affect your glucose levels and overall health differently. Also discussed healthier substitutions for common foods in our diet. Talked about the importance of moderation and appropriate portions, as well as the vital role water plays in maintaining healthy weight.

Audiogram/Hearing Exam

H91.9 Unspecified hearing loss
 H91.90 …… unspecified ear
 H91.91 …… right ear
 H91.92 …… left ear
 H91.93 …… bilateral
 
 
 H91.1 Presbycusis
 H91.10 …… unspecified ear
 H91.11 …… right ear
 H91.12 …… left ear
 H91.13 …… bilateral

Good Audiogram NOTE

Pt presents for audiogram f/u. Ears clear, no cerumen impaction noted. Unremarkable audiogram results. Explained that hearing results are within normal limits. Discussed hearing conservation with patient. Educational materials and results given to patient.

Poor Audiogram NOTE

Pt presents for audiogram f/u. Ears clear, no cerumen impaction noted. Significant Left-sided hearing loss on audiogram. However, when comparing to his records, no significant changes from his past recent audiograms. Discussed hearing conservation with patient. Educational materials and results given to patient.

Hemoglobin A1C or Serum Glucose

NORMAL A1C withOUT diabetes NOTE

Hemoglobin A1C in normal range (***%). No sign of diabetes or pre-diabetes at this time. Explained that the same diet and exercise changes that we give to those with elevated A1C, can also help stave off diabetes. We discussed the importance of heart healthy diet with complex carbs, good fats vs bad fats, lean protein, and minimal processed foods. We also discussed adding more foods like olive oil, avocados, walnuts, oatmeal, apples, oranges, salmon, and tofu. Recommended limiting foods like egg yolks, animal products, full-fat dairy, processed snacks, alcohol, simple carbs/starches, and sugars. Instructed to follow up in clinic in 2-3 months for cardio check to determine if changes have occurred with lifestyle changes.

Elevated A1C WiTH diabetes NOTE

Hemoglobin A1C of ***% shows excellent control of their diabetes. Explained importance of heart healthy diet with complex carbs, good fats vs bad fats, lean protein, and minimal processed foods. Discussed adding more foods like olive oil, avocados, walnuts, oatmeal, apples, oranges, salmon, and tofu. Recommended limiting foods like egg yolks, animal products, full-fat dairy, processed snacks, alcohol, simple carbs/starches, and sugars. Instructed to follow up in clinic in 2-3 months for cardio check to determine if improvement has occurred with lifestyle changes.

Elevated A1C WiTH PREdiabetes NOTE

Elevated hemoglobin A1C of ***% puts them just into the pre-diabetes range. Explained importance of heart healthy diet with complex carbs, good fats vs bad fats, lean protein, and minimal processed foods. Discussed adding more foods like olive oil, avocados, walnuts, oatmeal, apples, oranges, salmon, and tofu. Recommended limiting foods like egg yolks, animal products, full-fat dairy, processed snacks, alcohol, simple carbs/starches, and sugars. Instructed to follow up in clinic in 2-3 months for cardio check to determine if improvement has occurred with lifestyle changes.

Additional old Elevated glucose and A1C NOTE

Elevated hemoglobin A1C of ***%. Discussed monitoring glucose levels regularly and compliance with daily medication. Explained importance of heart healthy diet with complex carbs, good fats vs bad fats, lean protein, and minimal processed foods. Advised to follow up regularly with PCP or endocrinologist to monitor HgbA1C. Pt verbalized understanding and agreed to treatment plan.

Morgan's old NOTE (normal range A1C)

A1C result: ***. Explained that this is within normal limits for Hemoglobin A1C, and that pt is therefore not prediabetic or diabetic. Encouraged pt to maintain normal hemoglobin A1C and glucose levels by eating balanced meals and consistently exercising. Advised to moderate refined carbs and sugar to maintain normal levels.

Albuminuria consult Note

PATIENT INSTRUCTIONS: Proteinuria: Care Instructions

Microalbuminuria NOTE

Discussed the results of the albuminuria test.

• Albumin: 30
• Creatinine: 300
• A:C Ratio: <30
• A:C Ratio: 30 – 300
• A:C Ratio: > 300

Normal results.

Abnormal results - return for follow up testing. May be the result of working out or high protein consumption.

Protein in the urine may suggest the presence of a urine infection or may indicate the effects of diabetes on the kidneys. This helps identify who is at greater risk of developing kidney and heart disease in the future. Early treatment can be help prevent progression to more severe kidney damage in later years. Very good control of blood pressure combined with improving glucose control as much as possible have been shown to be very beneficial. Certain things increase the risk of developing albuminuria, including smoking, badly controlled blood sugar and/or blood pressure levels. Sometimes other factors can make the urine show small amounts of albumin in the laboratory test. For this reason, a single positive result is not confirmatory. You can help look after your kidney and hearts by stopping smoking (if you do), improving blood sugar control, improving your blood pressure, cutting down on dietary salt, and exercising regularly. By good control of diabetes (if you have it) and making lifestyle changes, you can help prevent the albuminuria from causing kidney and heart problems.

Tanita Consult Note

NOTE

Performed a Tanita body composition exam. Explained the results to the patient and gave them a printed copy of the results. Discussed following healthy lifestyle by engaging in regular exercise and following healthy diet. Discussed complex carbs vs. refined carbs, and how these can affect your glucose levels and overall health differently. Also discussed healthier substitutions for common foods in our diet. Talked about the importance of moderation and appropriate portions, as well as the vital role water plays in maintaining healthy weight.

Skin Screening Note

NOTE

Pt presents to clinic for skin cancer screening. Head to toe evaluation performed. Actinic keratosis observed on right lower extremity, and abnormal nevus on left forearm. Multiple skin tags, solar lentigos, and nevi observed on face, ears, trunk, and extremities. Encouraged follow up with dermatologist for further evaluation of AK and abnormal nevus. Pt verbalized understanding and agreed to treatment plan. Handout given to patient explaining how to identify skin cancer and ways to prevent skin cancer.

Allergen injection Note

NOTE

Justin is a healthy 29 yo Male with seasonal allergies and anxiety who presents today for his regular allergen injection. 0.5cc was injected into the right upper army subcutaneously and he waited in the waiting room for 30 minutes afterwards. He did not have any adverse reactions. A 1cm wheel was present initially, and was minimally present at the 30 minute mark. After the 30 minute wait, he asked for a refill for Lexapro. He stated that a fax was sent by the pharmacy, but we did not receive it, so I sent in a new prescription. He has reduced his dose to 10mg and is hoping to stop taking it altogether once his work stressors are reduced.

0.5mL of the allergen immunotherapy was injected subQ into the left arm and documented into Mitsy's book.

A 1cm wheel was present on each side with no redness, warmth, or systemic allergic symptoms

CPT codes 95115 (single injection) and 95117 (multiple injections) reflect the professional administration (injection) of the allergenic extract, when the extract is not included in the code descriptor.

Respirator Medical Surveillance Note

NOTE

FVC: *%
FEV1: *%
FEV1/FVC: *%

Normal Spirometry
Abnormal Spirometry: Possible Obstructive condition
Abnormal Spirometry: Possible Restrictive condition

Medical questions evaluated and were all negative or non-contributory for respirator use.

Has worn respirators frequently in the past with no issues or difficulties.

Pt passed OSHA respirator medical evaluation. Compliant. Credit issued.

Jean respirator note:
Pt completed OSHA Respirator Medical Evaluation Questionnaire. Passed health screening, credit issued.

DOT Medical Surveillance Note

NOTE

No concerning findings in UA, vital signs, vision, or hearing exams.

Medical questions evaluated and were all negative or non-contributory.

Pt passed DOT/FMCSA driver medical evaluation. Compliant. 2-year credit issued.