The patient is a 55 y/o male who presents to the ED due to having symptoms of dizziness, shaking, and a fast heartbeat.
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Get it written →Indicate if the medical documentation is complete. If the documentation is considered not complete, indicate what the provider needs to complete for an accurate code to be selected.
The patient is a 55 y/o male who presents to the ED due to having symptoms of dizziness, shaking, and a fast heartbeat. The patient has type two diabetes and is well-controlled with insulin. After evaluation, it is determined that the patient is experiencing a mild hypoglycemic episode and is treated with IV fluids and juice. The patient is monitored for two hours and sent home with a scheduled follow-up one week from the date.
Is this medical documentation complete?
If no, what documentation does the provider need to complete for an accurate code to be selected?
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