You’re probably undercoding. Here are two sample office notes:

CC: Cough

HPI: 75-year-old male with productive cough for five days, worse at night. Patient also has fever and chest pain. Patient using cough syrup without improvement.

PH: Non-smoker.

ROS: Denies shortness of breath or heart palpitations.

EXAM: Vitals: temp 101.5, BP 140/80
ENT: negative
Neck: negative
Chest: rhonchi bibasilar, pain on deep inspiration
CV: negative
Abd: negative

A/P: Acute bronchitis. Rx: Azithromycin, expectorant. Follow up as needed.

* * * * * * * * * *

CC: Chest pain

HPI: 58-year-old female with intermittent, sharp chest pain over two weeks. Episodes last 10 minutes at a time. Pain occurs at rest.

PH: Non-smoker, no family history of cardiovascular problems.

ROS: No shortness of breath. No reflux.

EXAM: Vitals: BP 120/80, P 65
Lungs: clear to auscultation
CV: normal

A/P: Chest pain. ECG and stress test ordered. Follow up scheduled.

They are both 99214′s. Code without fear.

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  • Anonymous

    Why didn’t you send the 2nd patient to the ER for admission? Not criticizing, just curious?

  • Anonymous

    I would probably order a chest xray on the first patient to rule out pneumonia and pleural effusion and depending on his clinical appearance, order blood cultures, CBC and BMP. I’ll probably give him an injection of Rocephin. And if I send him home, I’ll make sure somebody is staying home with him and caring for him.
    I’ll probably admit the second patient to a tele bed, consult with a Cardiologist, do stress test today or in AM.
    Would this be considered defensive medicine or standard of care? Just curious.

  • Anonymous

    Depends on if you’re talking to a group of tort reformers, or the insurance company paying for it.

  • Clinical Cases and Images

    It’s not Kevin, guys (all three anonymous commenters), the cases are from the AAFP’s Family Practice Management. Click on the “Code without fear” link above and you’ll see.

  • Anonymous

    How you work these up depends on whether you are an er doc or primary care. As a primary care, the first would definitely get a cxr to r/o pneumonia, lung ca, whatever. The second would probably get a cardiology referral for the stress/echo. Whether you send the patient to the er for a r/o MI depends on your gut feeling for whether the patient is litigious or not…anyone who is cranky or asks a lot of questions…that’s a red flag for “go to the er”; if it’s someone that you know and want to spare the hastle, then I go the second route…at my own peril…if one day I get burned I probably won’t do that anymore either…in a way it’s easier to be er because you have the easy option of admitting everyone. If you send everyone in primary care to the er you will alienate a hell of a lot of people…you have to pick and choose.

  • Anonymous

    let me correct one part of the above before I get flamed…it’s not easier to be an er doc, it’s just easier to make the decision regarding hospitalization…we both have our own sets of problems…

  • Anonymous

    Wow. I’m completely shocked at these responses. Clearly neither pt requires admission and the stated plans are appropriate. Admission of a pt with atypical chest pain and no cardiac risk factors is completely absurd.

  • Anonymous

    ” Admission of a pt with atypical chest pain and no cardiac risk factors is completely absurd.”

    Unfortunately there are plenty of “expert” witnesses out there who will be happy to testify that it is the “standard of care”.

  • Anonymous

    “Admission of a pt with atypical chest pain and no cardiac risk factors is completely absurd”

    Apparently, you have not been practicing medicine long enough, not to have seen your colleague send home a patient similar to the one above and die within 24 hr after being seen by a physician. Just talk to a malpractice defense lawyer and they will tell you. Or ask a cardiologist who has been in practice for more that 10 years. Or an ER doctor who has been in practice for several years.

  • Anonymous

    “Unfortunately there are plenty of “expert” witnesses out there who will be happy to testify that it is the “standard of care”.”

    And that’s the problem. In a reasonable world expert witnesses should be payed by and serve the court not the plantiff or defense. Essentially the story will go by who is paying the bill. Sharp chest pain at rest with normal vitals and no risk factors (except age). At most a PE could be ruled out (if CXR negative and that may be “defensive” on it’s own), set of troponins/CK’s done and the pt sent home with a close PCP/stress test follow up. Probably shouldn’t be admitted on a pure medical basis. But as we all know we don’t decide things for pure “medical” resons (and sometimes not for medical reasons at all). Something people like CJD will never understand.

  • Anonymous

    Yeah, the concept is too deep for me.

    What I don’t understand is why none of you “good” doctors ever make yourself available even to review malpractice cases. I mean, I know you don’t dare testify against your colleagues no matter what they did, but you’d think you’d at least be willing to do the pre-suit expert review almost all med mal cases undergo.

    CJD

  • Anonymous

    Well I went over to the ATLA winter convention 3 weeks ago and handed out my card with both phone and e-mail. I’d be glad to do chart reviews and expert testimony. So far , no response.

  • Anonymous

    What’s your name, address, and specialty? I’ll be glad to pass it on.

  • Bad Shift

    I’ve been looking to do reviews. Where do I sign up?

  • Anonymous

    Find out who does med mal in your area, call them and tell them you would be willing to review cases and what you would charge.

  • Anonymous

    “What’s your name, address, and specialty? I’ll be glad to pass it on.”

    Nice try…but we’re doctors, not stupid patients like you…what else you want my ss#?

  • Anonymous

    You are one pompous doctor. Glad my doctors don’t think of me as a “stupid patient” and treat me with respect.

    Where are you a doctor at by the way? An urgent care center? I’ve met doctors like you who feel your patients are below them. They
    typically give poor treatment as they just don’t care about what’s really going on.

  • Anonymous

    “What I don’t understand is why none of you “good” doctors ever make yourself available even to review malpractice cases. I mean, I know you don’t dare testify against your colleagues no matter what they did, but you’d think you’d at least be willing to do the pre-suit expert review almost all med mal cases undergo.”

    I know you seem to live on these blogs CJD but you really need to read for comprehension.
    I said “In a reasonable world expert witnesses should be payed by and serve the court not the plantiff or defense.”
    Don’t you think “good” docs would be happy to serve for the court to try to determine what REALLY happened and whether or not it is REALLY malpractice? I would. But there is no way in hell I would take money from a plantiff (or defense). Why is that? Because it results in an inherent bias period. If you take money from one side your testimoney is clearly going to be suspect to varying degrees. Why is this concept so hard for you to understand? By the way there is no “expert review” in my state to determine merit beforehand. That is unless you are talking about the review by the plantiff attorney themselves.

  • Anonymous

    I met a patient tonight with experience in oral testimony who would be perfect for testifying for your courts CJD. Prostitute came in looking for HIV meds after she was doing some paid “mouth work” and the condom break. Same sort of work, though less risky then her current way of making a living.

  • Anonymous

    ” Because it results in an inherent bias period. If you take money from one side your testimoney is clearly going to be suspect to varying degrees.”

    So if I give you money you can’t be honest? How sad.

  • Anonymous

    “Glad my doctors don’t think of me as a “stupid patient” and treat me with respect.”

    I probably am your doctor…we don’t say this stuff to your face…we pretend we care when we see you and when you leave we curse you for wasting resources with your stupid complaints…

  • Anonymous

    “So if I give you money you can’t be honest? How sad.”

    Hello is there anybody in there? Some of these creeps make a living off of testifying. Is it so hard for you to grasp that if a docotr is payed by the court instead by the plantiff/defense, his testimoney will be less (un) biased? Why do you think doctors can’t own significant stakes in facilities/labs they refer too? This isn’t just medicine. Cripes look around you. Do you want a financial planner who gets an extra cut based on what they sell?

  • Anonymous

    I guess it is only law where you can pay for somebody’s testimony and honestly believe it is unbiased.

  • Anonymous

    anon 8:32…I’m so happy that you practice in the UK where not much chance in hell I will ever see you grace the halls of an American hospital!

  • Anonymous

    i’m not in the uk, ass.

  • Anonymous

    Interesting comment’s.
    I don’t actually expect to have the lawyer’s on this site give an answer to the biases of paid experts as they directly benefit from the current system. Why look at a more honest ethical system when it could the JD’s bottom line.

  • Anonymous

    Yeah, because a bunch of physicians judging each other are sure to be unbiased. The comments here clearly illustrate how open minded most physicians are to a plaintiff’s case.

    Especially those willing to take time and lose money from their practices to review voluminous amounts of medical records and pleadings and listen to deposition testimony at a rate the state can pay. I’m sure they’ll be first rate. The only thing that will change is that you’ll be bitching about the cut rate “experts” that testify in your case when they disagree with you.

    Or are you volunteering to perform this service?

    CJD

  • Anonymous

    I suspect you would be surprised CJD. Many docs especially those in the last years of practice or recently retired would consider doing this. In my own town a practicing cardiologist (one of my residency mentors) well beyond retirement age regularly testifies/reviews in cases for little more than expenses. Why? Because he is utterly disgusted with the present system. He is appalled with how hired guns FOR BOTH SIDES will testify based on who is paying the bill. I suspect many many doctors in the twilight of their careers would be more than willing to be experts FOR THE COURT. These are the people who you want as expert witnesses, those with 30 years of experience in the field. How can you honestly and ethically argue the present system with it’s hired guns is better?

  • Anonymous

    Just passing through for my daily dose of poison. If there were any justice in this universe both the spewing doctors and the spewing lawyers would end up sharing a cell in Hell.

  • scipio

    After collapsing at home and having a heart rate of more than 200 beats per minute for around an hour, my wife saw her primary care physician and explained the episode she had experienced the night before and again that morning. Specifically she complained of chest pains, near syncope, heart palpitations, emesis, and exhaustion. He referred her to a cardiologist who said her symptoms suggested paroxysmal atrial fibrillation or an underlying tachyarrythmia and that her ECG demonstrated high voltage. He suggested she do a home pregnancy test. She was 40–wasn’t going to have another child. No more tests were done. and there are tests that would have discovered her right ventricular dysplasia. She died 17 days later–she was only 40. Who out there will break the “while wall.” Cardiologists would have put a man in the hospital with those symptoms–or at least would have realized she had an organic problem that required aggressive diagnostic workup.