Whole Visit: An Annual Physical

In practice

A patient arrives for an annual physical. After identity and insurance checks, the medical assistant measures his height on the stadiometer and weighs him, and calculates his body mass index. She seats him for five minutes before measuring his blood pressure with a correctly sized cuff on bare skin. She notes that he had coffee within the last half hour, records the reading with the arm and position, and reports it because it falls in a high category. As the provider ordered, she performs a distance vision screening at twenty feet, recording each eye separately and noting that he wore no glasses. The provider examines him, orders routine blood work, and orders a vaccine that he agrees to receive. The medical assistant collects the blood in the correct order and labels it in front of him. She checks the rights for the vaccine, finds the deltoid site using the landmark, gives the injection with a safety device, and observes him for the period the practice requires. At checkout, the visit is coded from the provider's documentation, and the vaccine is recorded with its route, site and time.