ICD-10 Documentation Example
S: Mrs. Finley presents today after having a new cabinet fall on her last week, suffering a concussion, as well as some cervicalgia. She was cooking dinner at the home she shares with her husband. She did not seek treatment at that time. She states that the people that put in the cabinet in her kitchen missed the stud by about two inches. Her husband, who was home with her at the time told her she was “out cold” for about two minutes. The patient continues to have cephalgias since it happened, primarily occipital, extending up into the bilateral occipital and parietal regions. The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. She denies any vision changes, any taste changes, any smell changes. The patient has a marked amount of tenderness across the superior trapezius.
O: Her weight is 188 which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70, respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart rate is regular and lungs are clear.
- Status post concussion with acute persistent headaches
- Cervical somatic dysfunction
P: The plan at this time is to send her for physical therapy, three times a week for four weeks for cervical soft tissue muscle massage, as well as upper dorsal. We’ll recheck her in one month, sooner if needed.
|S06.0x1A||Concussion with loss of consciousness of 30 minutes or less, initial encounter|
|G44.311||Acute post traumatic headache, intractable|
|M99.01||Segmental and somatic dysfunction of cervical region|
|W20.8xxA||Struck by falling object (accidentally), initial encounter|
|Y93.g3||Activity, cooking and baking|
|Y92.010||Place of occurrence, house, single family, kitchen|