WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: FLORA, VINCENT
ACCOUNT/EHR #: FLORVI001
DATE: 11/19/22
Attending Physician: Oscar R. Prader, MD
S: Pt is a 37-year-old female who was on vacation with friends. On a wager she parachuted from a plane and landed in a tree. She hit her head against a rock when she fell from the tree and lost consciousness for approximately five minutes. She says she has a headache and is a bit nauseated.
O: Ht 5′6″ Wt. 130 lb. R 18. T 98.1. BP 122/83. HEENT unremarkable. PERRLA. Dr. Prader notes slight slurred speech. EEG shows indication of a head trauma. CT scan confirmed the brain concussion. Patient was admitted to the hospital for observation.
A: Concussion with brief loss of consciousness
P: 1. Watch for 24 hours
2. Discharge home if no further complications.
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What is/are the correct diagnosis code(s) for the concussion?
