HPI: Establish Care. No other concern today. Has had flu shot.
Pt is here to establish care today. She is transferring care from another of our clinics. She denies any specific questions or concerns today.
Pt reports overall she has been fairly healthy. She had a hip surgery earlier in the year. Unfortunately, she fracture her wrist this year. Being treated for osteoporosis.
Patient states she is likely due for mammogram. She states it has been about 2 years since her last assessment. I do not see record on file.
Patient states that she has a 7 yr old daughter and a 9 yr old daughter. She reports both girls keep her very active and healthy. She has never smoked, is retired and Married. Does not use alcohol or recreational drugs.
ROS was extended
PE was expanded problem focused
Impression and recommendation:
Osteoporosis, patient is to continue treatment, when able increase weight bearing exercise.
Screening mammogram ordered.
Should this be billed out? Being an established patient from one of our other clinics, new to this provider, with no complaints. Yes, mammogram was ordered. No mention of followup.