Emergency Department Note PATIENT: Samantha Hill DATE OF S…

  Emergency Department Note PATIENT: Samantha Hill DATE OF SERVICE: 12/31/XX AGE: 23 Samantha was brought in by ambulance. She was at a New Year’s Eve’s party, and she had been drinking alcohol for 4 hours and passed out. According to her friend who accompanied her to the ER, Mary does not have an alcohol addiction and has no known medical conditions. Physical Exam: Pupils are dilated. HEART: Heart rate is decreased. ABDOMEN: No abnormal findings Patient has limited response to questions. While she was in the emergency room, she started to vomit. She was observed for 7 hours and then sent home. She was advised to seek counseling for possible alcohol addiction. DIAGNOSIS: Alcohol abuse with intoxication. Blood alcohol level unspecified ICD-10-CM Code Assignment: