miss professor
Miami Regional University (Acct #3111) |
Case ID #: 1332-20170609-006 | Date of Service: 6/9/2017 |
Student Information - Norona, Maria | |
Semester: | Summer |
Course: | MSN6050 Advanced Practice in Primary Care II |
Preceptor: | BATISTA, JULIO |
Clinical Site: | Julio Batista Ortiz Medical Center |
Setting Type: | Underserved area/population |
Patient Demographics | |
Age: | 29 years |
Race: | Hispanic |
Gender: | Female |
Insurance: | Private insurance |
Referral: | No referral |
Clinical Information | |
Time with Patient: | 30 minutes |
Consult with Preceptor: | 15 minutes |
Type of Decision-Making: | Moderate complexity |
Reason for Visit: | Episodic |
Chief Complaint: | " Follow up an abnormal pap smear." |
Encounter #: | 2-5 |
Type of HP: | Problem Focused |
Social Problems Addressed: | Sanitation/Hygiene |
Procedures/Skills (Observed/Assisted/Performed) | |
Physical Assessment - Physical Assessment (Perf) |
ICD-10 Diagnosis Codes | |
#1 - | N87.9 - DYSPLASIA OF CERVIX UTERI, UNSPECIFIED |
CPT Billing Codes | |
#1 - | 99214 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: DETAILED HX; DETAILED EXAM; MED DECISION MOD COMPLEXITY |
#2 - | 57455 - COLPOSCOPY, CERVIX W/UPPER ADJACENT VAGINA; W/BIOPSY(S), CERVIX |
#3 - | 2010F - VITAL SIGNS DOCUMENTED AND REVIEWED |
#4 - | 99407 - TOBACCO USE CESSATION INTENSIVE >10 MINUTES |
Birth & Delivery |
Medications | |
# OTC Drugs taken regularly: | |
# Prescriptions currently prescribed: | |
# New/Refilled Prescriptions This Visit: | |
Types of New/Refilled Prescriptions This Visit: | Adherence Issues with Medications: |
Other Questions About This Case | |
Patient's Primary Language: | Spanish |
Smoking Assessment: | Current Smoker |
Advanced Directive: | No |
Packs per day: | 15-20 cigarettes |
Clinical Notes | |
CC: " Follow up an abnormal pap smear." |