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CLINICAL EXAMPLE 99241
 

 
Office consultation for a female with a forearm contusion

Reason for consultation : Left arm pain     

Requesting clinician : Jane Doe, ARNP

HPI : The patient is a 41 year old female referred from an urgent care clinic for left arm pain.  She was playing tennis yesterday when she accidentally hit her left forearm with her own racquet.

Physical Exam

Left forearm has a slight bruise.  No swelling or erythema; no effusion in the wrist.  Normal grip strength

Assessment
  1. Left forearm contusion
Plan
  1. Rest
  2. No further treatment needed
  3. Re-evaluate PRN if no improvement in one week
  4. Will send a copy of this note to Jane Doe, ARNP

For a detailed breakdown of this note with tips and advice see  99241 E/M Insight

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