CHART NOTE CC: This Established Patient Presents to the Office Today with Today

question 8

Short Answer

CHART NOTE
CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks' duration.
OBJECTIVE: This is a 50-year-old male in apparent good health. His BP is 119/78. Rectal examination showed a grade 1 hemorrhoid in the 2 o'clock position approximately 2 cm across. The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted.
ASSESSMENT: Hemorrhoid.
PLAN: Discussed conservative treatment options with the patient and explained surgical option. He wants to try the more conservative approach of stool softeners, warm and sitz baths. I discussed with him the importance of improved bowel habits. He is to return for a recheck in 2 months. The medical decision making was of straightforward complexity.
CPT Code: ____________________

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Definitions:

fMRI

Functional Magnetic Resonance Imaging, a brain imaging technique that measures brain activity by detecting changes associated with blood flow.

Anatomical Imaging

The technique of creating visual representations of the interior of a body for clinical analysis and medical intervention.

Functional Imaging

Techniques that visualize and measure brain activity by detecting changes associated with blood flow, often used in neuroscience.

Brain Activity

The functioning of the brain as it engages in various cognitive, perceptual, and motor tasks, often measured by physical or biochemical means.