ICD-10 Chief Complaint:
Physical Exam:
General Appearance: well-nourished, well developed in no acute distress. Orientation: oriented to person, place and time. Mood / Affect: calm. Gait: normal Coordination: normal
Diagnostic Studies:
Xray series of the hand including P/A, lateral and oblique views dated today were personally evaluated by me and demonstrates the following: Fracture (s) and/or Dislocation(s): None . Alignment: Normal . Joint space(s): Normal . Soft tissues: Normal .
Assessment:
S60.221A Contusion of right hand, initial encounter
Plan:
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered.
Category:
- Injury
ICD-10:
S60.221A
ICD:
S60
Side:
- Right
Encounter:
- Initial
ICD-10CM Year:
2019