coding applications

HOSPITAL COURSE: We did give her a tetanus shot and 1 g of Ancef. I immediately gave her some parenteral Fentanyl and Versed, and we were able to reduce the dislocation without difficulty. Postreduction film looks surprisingly good. There is perhaps a subtle fracture noted only on the lateral projection. C-Spine shows some degenerative change, is of poor quality, but is negative; upon re-examination she is not tender in that area. However, it was done because she had such a severe distracting injury and given the mechanism. Chest x-ray and left femur look fine.
ASSESSMENT: Level 3 trauma with an open right ankle dislocation, multiple abrasions.
PLAN: Plan to call Dr. Almaz, who graciously agreed to assume care. The patient is kept n.p.o.

Using the E/M Audit Form provided in Appendix A of your text book, please answer the following question:


What level of exam was performed? ____________________