Instruction. Review the reports and create summaries for each patient using the

Instruction.

Review the reports and create summaries for each patient using the format below. Google the diagnosis for the CPT/ICD-10 codes. Include CPT/ICD-10 codes for each diagnosis.

Sample:

Age: 74 Years

Gender: F

Chief Complaint: Follow-up appointment for my diabetes

Plan of Care: Patient is doing well, denies any problems with blood sugar or current symptoms. Blood pressure 116/78, HR 72, RR 16, Temp 98.2. Lung sounds clear all lobes. Cardiac S1 S2 heard with no murmur. No peripheral edema noted. Pedal pulse 3+ bilaterally. No sores noted to bilateral feet. Feet well-groomed. Denies peripheral numbness or tingling. Denies trouble with vision. Last eye exam within last 6 months. Plan: Continue taking Lisinopril 10mg daily for blood pressure. Continue following diabetic diet low in sodium; educated patient on diet. Continue taking Januvia 100mg by mouth daily. CBC, CMP, A1c, fasting lipid panel, and TSH to be drawn today. Follow-up in 6 months. Return to clinic for any problems.

CPT/ICD-10: 99214; E11.9 Type 2 diabetes mellitus without complications, I10 Essential hypertension.