tci ED Coding & Reimbursement Alert - 1999 Issue 7

Patient Medical Record

History of Present Illness (HPI): The patient is a 51-year-old female who fell down six stairs just prior to arrival and injured her right upper extremity, her left knee, and her left ankle. She denies other injuries, symptoms, or complaints. She denies any head trauma, neck, or back injury. She is transported to the emergency room via ambulance with paramedics in attendance. Radio control was established en route. She arrives immobilized on a long spine board. Review of Systems (ROS): Negative for chronic illness or conditions other than some osteoarthritis and hypertension. Patient, Family, Social History (PFSH): No alcohol...

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