Name of the Procedure:

Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient

Summary

This procedure involves a medical office or outpatient clinic visit for an established patient, focusing on a relevant history and/or examination followed by straightforward medical decision-making. The visit typically lasts between 10-19 minutes based on time used for code selection.

Purpose

This visit addresses ongoing or new health issues and aims to manage and evaluate the patient's current medical conditions.

Indications

• Chronic disease follow-up (e.g., hypertension, diabetes)
• Management of acute symptoms (e.g., cough, mild pain)
• Medication management or adjustments
• Routine health check-ups
• Monitoring after hospitalization or surgery

Preparation

• No fasting or special preparation is usually required.
• Patients should bring a list of current medications and any recent test results.
• A brief description of any new symptoms or issues.

Procedure Description

1. Patient check-in and update of medical records.
2. A medically appropriate history is taken and/or a physical examination is performed.
3. Discussion of symptoms, medical history, and any recent changes.
4. Medical decision-making to address any health concerns is based on gathered information.
5. May include ordering of tests, prescribing medications, or providing a treatment plan.

Tools: Patient records, blood pressure cuff, stethoscope, basic diagnostic tools.

Duration

Typically lasts 10-19 minutes.

Setting

Performed in a doctor's office or outpatient clinic.

Personnel

• Primary Healthcare Provider (e.g., Doctor, Nurse Practitioner)
• Medical Assistant (for initial intake and vitals)

Risks and Complications

Generally, there are minimal risks associated with a standard office visit. Rarely, miscommunication or incomplete history might lead to inadequate treatment.

Benefits

• Effective management of ongoing health conditions.
• Early detection of potential new health issues.
• Personalized healthcare advice and intervention.

Recovery

• No specific recovery period is necessary as the visit is non-invasive.
• Patients may need to follow specific advice or treatment plans provided during the visit.

Alternatives

• Telemedicine visits for minor conditions or follow-ups.
• Urgent care visits for more immediate but non-emergent issues.

Patient Experience

• The visit may involve discussing personal health information and a physical examination.
• Generally painless; minor discomfort may be experienced during certain examinations (e.g., ear, throat).

Pain management and comfort measures: Typically, these visits are not painful, and any discomfort from examination is brief and minimal.