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RECORD ENCOUNTER (OPTIONAL)
I confirm the patient has been informed this visit is being recorded to assist with documentation.
Chief Complaint
Chest pain and shortness of breath for 2 days
Vitals
BP
148/92
HR
88
Temp
98.4
HPI
58-year-old presents with intermittent substernal chest pressure radiating to the left arm, worse with exertion, associated with mild dyspnea.
Review Of Systems
Positive for chest pain, dyspnea on exertion.
Past Medical Hx
Type 2 diabetes, hypertension
Past Surgical Hx
Appendectomy 2004
Family History
Father with MI at age 60
Assessment
Chest pain, likely cardiac etiology given risk factors — rule out ACS.
Plan
Patient's Name
Smith, John
Insured's Name
Smith, John
Dx A
E11.9
Dx B
I10
Dx C
N18.2
Dx D
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Date Of ServiceCPT CodeDx PointerCharges
Total Charge—
Claims Overview
AllPendingDeniedPaid
PatientCPTPayerAmountStatus