the level of history taking achieved – identify the history elements present

It is noted, “there are a host of coding changes, including substantial revisions to evaluation and management (E/M) services that occur in hospitals or nursing homes, and changes to how prolonged services can be reported” (Moore et al., 2023, p. 22). The level of history achieved within the SOAP note can be described as in depth which can range from 30-44 minutes for completion. The history elements present are past medical history, social history, and medications. The CPT E/M code used for new patient encounter is 99203 due to estimated completion time of 30-44 minutes. 

the type of exam performed – identify the number of systems and bulleted points in the note

The type of exam performed can be described as comprehensive due to elements of history taken. The number of systems identified were thirteen. The bulleted points addressed components in relation to complaints for appropriate diagnosis and therapeutic interventions.

the level of medical complexity encompassed – include # of points for a) diagnoses/management options, b) amount/complexity of data reviewed and c) level of risk for complications, morbidity, mortality

The level of medical complexity addressed showed diagnosis of Tinea Versicolor and Alcohol abuse. The number of points for diagnoses/management options are 3 points due to no work up planned. The amount/complexity of data reviewed consists of two points due to independent review of imaging and data. The level of risk for complications, morbidity, and mortality are low due to management criteria. 

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