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PRADER, BRACKER, & ASSOCIATESA Complete Health Care Facility

159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789

 

PATIENT: KIM, LINDA

ACCOUNT/EHR #: KIMLI001

DATE: 09/16/18

 

Attending Physician: Oscar R. Prader, MD

 

S: This new Pt is a 29-year-old female who presents with splatter burns on the back of her right hand and her right cheek. She stated that she was deep-frying shrimp for a dinner party at her home in the kitchen and the grease splattered unexpectedly.

 

O: Ht. 5′6″, Wt. 152 lb., R 20. Skin is red and blistered on both sites. There is some epidermal loss. Area was cleansed with antiseptic, and ointment was applied before a clean gauze bandage was put on the hand. The facial area was also cleansed and bandaged.

 

A: Second-degree burns to back of hand and face.

 

P: 1. Rx: Aspirin for pain, prn

   2. Return in 1 week for dressing change.


  determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate

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