LOCATION outpatient, Clinic PATIENT Jane Smith ATTENDING

LOCATION outpatient, Clinic PATIENT Jane Smith ATTENDING PHYSICIAN: George Orbitz, M_D_ I had a lengthy conversation with the three children of Ruth Fillmore, along with an interdisciplinary team of 4. Their mother is on dialysis for her end-stage renal disease. We explained to them that the patient has dementia and is very loud in the dialysis unit. she is very forgetful. Her blood pressure has dropped to the 60 systolic range and she is hypoxic. The patient’s children decided to make her code-level Ill and not take her to the hospital, which we all agreed With. We discussed stopping dialysis and it was the team’s impression that she would be off dialysis. However, one of her sons called me Monday night indicating that there was some misunderstanding on his part and that he wants his mother to continue on dialysis. During the team conference, we discussed with the patient’s children the quality of life of the patient in that dialysis is not really doing anything and it is probably inadequate anyway. They wanted to continue With dialysis; therefore, the patient had a dialysis treatment on Wednesday. In general, her blood pressure was better and she was not hypoxic. I left it to them to decide when to stop dialysis, but at this time we will continue the current dialysis prescription. The total amount of time spent was an hour and 15 minutes. Assign CPT – ICD-10-CM –

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