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Emergency Department Record CHIEF COMPLAINT: Scalp laceration HISTORY OF PRESENT ILLNESS: Patient is an 88-year-old white female who lost her balance and fell in her room today, hitting her head and sustaining a laceration of her right scalp. No loss of consciousness. No syncope. No neck pain. No vomiting. She has been acting normally since the injury, according to her daughter. PAST MEDICAL HISTORY: Hypertension, dementia MEDICATIONS: Colace, iron, hydrochlorothiazide, Paxil ALLERGIES: None IMMUNIZATIONS: Not up to date PHYSICAL EXAMINATION: GENERAL: Alert female in no acute distress HEAD, EARS, EYES, NOSE, AND THROAT: There is a 3.5-cm full skin thickness scalp laceration. Minimal swelling. No deformity. Pupils are equal and reactive to light. Extraocular muscles intact. Tympanic membranes normal. Oropharynx negative. NECK: Supple. Nontender. HEART: Regular. No murmurs or gallops noted. LUNGS: Breath sounds equal bilaterally and clear. EXTREMITIES: Atraumatic. Full range of motion. NEUROLOGICAL: Awake, alert, and oriented to person. Not to place or time. No focal motor. Moves all extremities symmetrically. Deep tendon reflexes 1+. PROCEDURE: Anesthesia local injection 3 cc lidocaine with epinephrine. Prepped. Explored. No foreign body noted. Closed in a single layer with interrupted staples. Polysporin ointment was placed. Care instructions; head injury instructions; staples out in 10-12 days. What was the treatment for the laceration? What key pieces of documentation are needed to code this case? Time to Code: Index: Code(s) Index for Skin G Code(s):

Emergency Department Record
CHIEF COMPLAINT: Scalp laceration
HISTORY OF PRESENT ILLNESS: Patient is an 88-year-old white female who lost her balance and fell in her room today, hitting her head and sustaining a laceration of her right scalp. No loss of consciousness. No syncope. No neck pain. No vomiting. She has been acting normally since the injury, according to her daughter.
PAST MEDICAL HISTORY: Hypertension, dementia
MEDICATIONS: Colace, iron, hydrochlorothiazide, Paxil
ALLERGIES: None
IMMUNIZATIONS: Not up to date
PHYSICAL EXAMINATION:
GENERAL: Alert female in no acute distress
HEAD, EARS, EYES, NOSE, AND THROAT: There is a 3.5-cm full skin thickness scalp laceration. Minimal swelling. No deformity. Pupils are equal and reactive to light. Extraocular muscles intact. Tympanic membranes normal. Oropharynx negative.
NECK: Supple. Nontender.
HEART: Regular. No murmurs or gallops noted.
LUNGS: Breath sounds equal bilaterally and clear.
EXTREMITIES: Atraumatic. Full range of motion.
NEUROLOGICAL: Awake, alert, and oriented to person. Not to place or time. No focal motor. Moves all extremities symmetrically. Deep tendon reflexes 1+.
PROCEDURE: Anesthesia local injection 3 cc lidocaine with epinephrine. Prepped. Explored. No foreign body noted. Closed in a single layer with interrupted staples. Polysporin ointment was placed. Care instructions; head injury instructions; staples out in 10-12 days.
What was the treatment for the laceration?
What key pieces of documentation are needed to code this case?
Time to Code:
Index:
Code(s)
Index for Skin G Code(s):

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