Episodic?visits are mostly encounters which require about one time visit (sometimes with a short follow-up depending on the diagnosis/existing comorbidities), or occurs occasionally. ?

Episodic Write-up
School of Nursing and Allied Health
MSN Case Write Up Assignment
The purpose of the Case Write- Up Assignment is for your instructor to?”see” what you are doing in clinical and “see” how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will write-up?? the visit, omitting any identifying patient factors. Ensure your write-ups demonstrate comprehensive advanced practice thinking and not just the new skills of ordering and prescribing.
Make sure to start fresh??. Do not copy and paste from any examples, templates, other students work or even your own work. Put all your old case write-ups away and give your brain a chance to formulate the note so that it really becomes a part of what you know. THAT will make you a competent NP.
Be honest in your write up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, just put a note at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups, but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve?your own practice.
If your preceptor orders something that is not appropriate or fails to order something that you believe should have been part of the plan, write a note at the end of the write-up to let your instructor know that you are aware and what you would have done. You are not responsible for what your preceptor orders, but you are responsible for knowing the appropriate plan of care and you are responsible for knowing if a plan of care is inappropriate.?You and your faculty are the only ones that see the write-up, so no feelings will be hurt. We all get set in our ways and tend to order the same thing over and over. If your readings and research indicate that another plan is more appropriate, write it as an addendum or in parentheses in the plan.
You are learning to practice evidence-based practice. Support at least one item in the assessment AND plan with research. This can be your textbook and/or other class readings. The best way to support your research is using a research article. Make sure that the article is current (5 years or less old). The article can be used to support the use of the medication (or other therapy) for the presumptive diagnosis. When using an article, please attach the article along with the write-up into the appropriate assignment category. Failure to cite your plan will result in a?point penalty reduction (see rubric for additional information)
Note that you CANNOT redo write-ups. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups
All case write ups are to be submitted to SafeAssign and the appropriate assignment category by the due date. Failure to submit to SafeAssign will incur a penalty of 5 points per day including weekends (maximum deduction of 25 pt.). Late submissions to the appropriate assignment category will incur a 5pt/day penalty (no maximum) including weekends unless an extension has been requested and approved before the due date.
Episodic?Write-up: Episodic?visits are mostly encounters which require about one time visit (sometimes with a short follow-up depending on the diagnosis/existing comorbidities), or occurs occasionally. ?Episodic?visit ROS and physical examination (PE) are targeted and focused on the body system(s) affected. ?Examples are URI, bronchitis, seasonal allergic rhinitis, acute pharyngitis, acute gastroenteritis, pneumonia, contact dermatitis, etc.
This write-up should be 2-4 pages single spaced and concentrate on the most pertinent information. Not all the systems or sections from a comprehensive write up will be represented. Only the sections and information that are important to this case need be included. This helps clarify your understanding of using only the best/most important tools and information to justify your critical thinking.
Comprehensive Write-up:?Comprehensive visits often requires head to toe or extensive ROS and physical examination (PE). Visits which may necessitate a comprehensive ROS, physical exam, and write-up include annual physical, well woman exam(may not always include head to toe, but could be the only preventive care most women receive), well child exam, new or established patients with complex or chronic diseases or comorbidities, non-specific complaints, such as fatigue, generalized weakness or body ache, dizziness, etc.? This write up should be 5-8 pages single spaced.
You must know how to delineate which visits are?episodic?versus comprehensive. ?Conducting a comprehensive exam on a patient whose chief complaint and ROS support an?episodic?visit or write-up may paint a picture of a clueless provider; and can constitute a waste of time for you and the patient. Your patient may not trust your clinical reasoning/judgment (diagnosis/plan of care) if they perceive you are all over the place! ?Insurance is not going to pay you more because you decided to complete a comprehensive note on an?episodic?visit or diagnosis!??
Alternative Write-up: Some courses may have specialized write-ups based on a patient with certain demographics or with certain disease process. These write ups will follow the same guidelines as comprehensive-write ups.
Case Write-up Outline
Following the format of: .
Subjective:
CC: This should be in quotes: Ive had a cough and sore throat for 2 days??
HPI: One of the most important parts of the assessment. Check the list of important questions to ask (OLD CARTS or PQRST). As you become more proficient in physical exam and lab testing, the HPI does not decrease in importance – your ability to use it in diagnostic reasoning just increases.?
Past Medical History: Past or present illness. Be careful with blindly?? copying history from a prior clinical note.
Past Surgical History: Past surgeries and rough dates when possible. Should also include traumas and hospitalizations
Medications: List name, dose, frequency and indication (why are they taking it?) Do NOT omit the indication (reason) for a specific drug being taken. Do NOT omit PRN medications and how often the medications are taken. This is one way to check whether youve put all important information in your patient history. If a patient is taking Metformin and theres no related information on the history and/or diagnoses list, something is missing.
Allergies: Medications. Food allergies when applicable.
Social History: This includes several factors: alcohol use, cigarette use, sexual history, work history are a few examples. Include health promotion information such as exercise and immunizations. Immunization is important – we want to know the date of an adult patient’s last tetanus immunization. Be specific, dont just say UTD. For children, list dates for all immunizations.
Family History: It is generally appropriate to go back at least two generations.
Obstetrical History: When appropriate, document number of pregnancies and other relevant information.
Review of Symptoms (ROS): For comprehensive visits: should be extensive and include every system. For episodic visits: Think about your likely differential diagnosis list and tailor your ROS to it. Always address growth and development in pediatric patients. In childbearing women, make sure to document date of last menstrual period (LMP) and methods of contraceptive use on every visit on any woman capable of becoming pregnant (having menses and has not had a tubal ligation/hysterectomy). Every visit – If you order such a medication without documenting the above information, we have to assume that the patient could be pregnant (as would any lawyer in a lawsuit). For a young teen you can put not sexually active?? (but make sure you have asked). This is sometimes tricky with teens being seen for general health problems but so very important. If in any doubt, ask the parent to step out for a moment so that you can talk to the teen alone.
Objective
Vital signs (BMI should be included on every visit)
Physical examination
Laboratory data, diagnostic tests, imaging: These should be what is available at the time the visit. Do not include testing that was ordered during the visit but not results were not available.
TIP:
Make sure to proper distinguish between subjective and objective data. Subjective data, as the name suggests, is the information you gather by interviewing the patient, family, or significant other. This will include data from chief complaint, Social/family history, and Review of system (ROS). Objective data will include those information or data you elicited through physical examination, vital signs and/or diagnostic test results.?Note that statement such as Denies chest pain, sob, dysuria, vaginal bleeding, diarrhea, etc.?? should be in the subjective section (ROS) of your note, and not in PE section.? Do not write Alert and oriented; no tenderness; no erythema; breath sounds clear; no spine curvature?? under ROS or subjective section. These are objective findings. You elicited these data through your physical examination of the patient.
Assessment
List both your differential diagnoses and your presumptive diagnosis. Remember that these should be supported by findings in your history and physical exam. For a comprehensive exam, you should document at least three ICD code diagnoses.
Plan
Include medications ordered, labs tests, teaching, referrals, and when the patient needs to follow-up. All write-up plans should include documentation of patient education, especially if medication is prescribed and anticipatory guidance.?Health maintenance such as screening for breast or colon cancer, should be addressed.

Coding Resource:
All write ups should include the billing codes. We do not expect you to memorize these codes. You can get them from the billing form that the physician or NPs uses in the office. You can put the billing codes at the end of the write-up. You should include both the E&M code (level of service) and the ICD-9 diagnosis codes. Your E&M code should be consistent with your patient visit.

MSN Case Write-Up Rubric
2021 E&M Coding ToolTODAYS PROBLEM LEVELTODAYS DATA LEVELTODAYS RISK LEVELTODAYS TIMETODAYS VISIT (Circle one)LEVEL: 2 3 ?4 5 (Circle one)LEVEL: 2 3 ?4 5 (Circle one)LEVEL: 2 3 ?4 5TOTAL TIME ON DOS: ______________ (Circle one)LEVEL: 2 3 ?4 5Number & Complexity of problems addressedAmount and/or Complexity of DataEach unique test, order, or document contributes to a combination of 2 or of 3 in Category 1 below.Riskof morbidity from additional diagnostic testing or treatmentTimeSee reverse side for time calculation tool based on activitiesFinal Level assigned, based on MDM or Total TimeLEVEL 21 self-limited or minor problemLEVEL 2Minimal or noneLEVEL 2Minimal riskLEVEL 2 15??29 mins NEW: 9920210??19 mins EST: 99212LEVEL 3 ཛྷ2 or more self-limited or minor problems; or ཛྷ1 stable chronic illness; or ཛྷ1 acute, uncomplicated illness or injuryLEVEL 3 One category requiredCATEGORY 1: Any 2 from the following: ཛྷReview of prior external note(s) from each unique source; ཛྷOrdering of each unique test or ཛྷReview of the result(s) of each unique test;CATEGORY 2: ཛྷAssessment requiring an independent historian(s) For independent interpretation and discussion of management or test interpretation, see Level 4 or 5.LEVEL 3Low riskLEVEL 3 30??44 mins NEW: 9920320??29 mins EST: 99213LEVEL 4 ཛྷ1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or ཛྷ2 or more stable chronic illnesses; or ཛྷ1 undiagnosed new problem with uncertain prognosis; or ཛྷ1 acute illness with systemic symptoms; or ཛྷ1 acute complicated injuryLEVEL 4 One category requiredCATEGORY 1: Any 3 from the following: ཛྷReview of prior external note(s) from each unique source; ཛྷOrdering of each unique test or ཛྷReview of the result(s) of each unique test; ཛྷAssessment requiring an independent historian(s) orCATEGORY 2: ཛྷIndependent interpretation of test performed by another MD/QHCP/appropriate source (not separately reported); or CATEGORY 3: ཛྷDiscussion of management or test interpretation with external MD/QHCP/appropriate source (not separately reported)LEVEL 4Moderate RiskEXAMPLES ONLY: ཛྷPrescription drug management ཛྷDecision regarding minor surgery with identified patient or procedure risk factors ཛྷDecision regarding elective major surgery without identified patient or procedure risk factors ཛྷDiagnosis or treatment significantly limited by social determinants of health LEVEL 4 45??59 mins NEW: 9920430??39 mins EST: 99214LEVEL 5 ཛྷ1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or ཛྷ1 acute or chronic illness or injury that poses a threat to life or bodily functionLEVEL 5 Two categories requiredCATEGORY 1: Any 3 from the following: ཛྷReview of prior external note(s) from each unique source; ཛྷOrdering of each unique test or ཛྷReview of the result(s) of each unique test; ཛྷAssessment requiring an independent historian(s) orCATEGORY 2: ཛྷIndependent interpretation of test performed by another MD/QHCP (not separately reported); or CATEGORY 3: ཛྷDiscussion of management or test interp with external MD/QHCP/appropriate source (not separately reported)LEVEL 5High RiskEXAMPLES ONLY: ཛྷDrug therapy requiring intensive monitoring for toxicity ཛྷDecision re: elective major surgery with identified patient or procedure risk factors ཛྷDecision re: emergency major surgery ཛྷDecision re: hospitalization ཛྷDecision not to resuscitate or to de-escalate care due to poor prognosisLEVEL 5 60??74 mins NEW: 9920540??54 mins EST: 99215ABOUT THIS TOOL This tool is a guide for leveling outpatient E&M services using Medical Decision Making (orange) *OR* Time (blue). The reverse may be used to assist with capturing all applicable activities in the clinicians time total.NOTES: 3452Adapted from: Table 2 ??CPT E/M Office RevisionsLevel of Medical Decision Making (MDM) https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdfCPT is a registered trademark of the American Medical Association. Copyright 2019 American Medical Association.
2021 E&M Coding ToolTIMEActivitiesTime Spent (MINUTES)Include ALL minutes clinician spent on patient on DOSPre-VisitReviewing notes, results, correspondence, reports (Note sources, dates)Other:VisitHistory from patient and others (Note sources)History, examination, discussion, counseling, education, planningOrdering, referrals, documentingPlanning, ordering, referralsOther:Post-VisitDocumentingReviewing and communicating resultsIndependent interpretation of tests (not separately billed)Care coordination (not separately billed)Other:TOTAL TIME ON DOSREFERENCENew PatientEstablished PatientLEVEL 215??29 mins 9920210??19 mins 99212LEVEL 330??44 mins 9920320??29 mins 99213LEVEL 445??59 mins 9920430??39 mins 99214LEVEL 560??74 mins 9920540??54 mins 9921520 Winooski Falls Way, Suite 7, Winooski, VT 05404Toll-free: 800-722-7708 Email: [email protected]: www.pcc.com

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