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: ____________________

Comprehend the principles of social cognitive theory.

Recognize the humanistic perspective on self and identity.

Grasp the foundational concepts of learning theories in behavior.

Learn about the sociocultural perspective in understanding personality.

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Definitions:

Skill Categories

The classification of skills into groups based on similarities, such as technical, interpersonal, and analytical skills, for the purpose of evaluation and development.

Structural Considerations

Factors related to the organizational, physical, or logical arrangement of a system or enterprise that need to be taken into account when planning or evaluating.

Management Function

The organizational activities of planning, organizing, leading, and controlling to achieve goals efficiently and effectively.

Chain Of Command

The formal line of authority within an organization, defining who reports to whom, from the highest levels of leadership down to frontline employees.