Location: Emergency Room SUBJECTIVE: This Is a 38-Year-Old Female Who Presents to the Presents

Short Answer

Location: Emergency Room
SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday. She states she was seen by the "eye doctor earlier today" and now has a bandage over her eye. Apparently her eye is opened underneath the bandage and she is unable to close her eyelid. She feels her eyelid is stuck to the bandage.
OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this. The Telfa was removed and a wet patch was placed. This did provide significant comfort. Her eye patch was reinforced.
ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as described above.
PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her she needs to keep that appointment. She is to return here sooner if she is having increasing problems.
CPT Code: ____________________