Hemiplegia Documentation Template:

Patient presents with complete unilateral paralysis affecting the rightleft side of the body, consistent with hemiplegia.  Onset was suddenabruptgradual following a cerebrovascular accidentstrokebrain attack on date.  Neurological examination reveals absent voluntary movement in the affected rightleft upper and lower extremities.  Deep tendon reflexes are hyperreflexiahyporeflexiaabsent in the affected limbs.  Muscle tone is spasticflaccid in the affected side.  Sensory testing demonstrates rightleft sided hemianesthesiahypoesthesiaparesthesia.  Patient exhibits facial droop and dysarthria.  Differential diagnosis includes stroke, traumatic brain injury, and spinal cord injury.  MRI brain confirmed ischemichemorrhagic stroke affecting the leftright cerebral hemisphere.  Current treatment plan includes physical therapy, occupational therapy, speech therapy, and medication management for blood pressure and cholesterol control.  Patient requires assistance with activities of daily living.  Prognosis for functional recovery is guarded.  ICD-10 code I69.39 I69.4 I69.9 will be utilized, along with appropriate CPT codes for evaluation and management, therapy services, and diagnostic imaging.

Hemiparesis Documentation Template:

Patient presents with unilateral weakness affecting the rightleft side of the body, consistent with hemiparesis.  Symptoms include difficulty with movement and decreased strength in the affected rightleft upper and lower extremities.  Onset was gradual following a transient ischemic attackmini strokestroke on date.  Neurological examination reveals reduced muscle strength grade strengthnumber out of five in the affected limbs.  Deep tendon reflexes are brisknormaldiminished in the affected side.  Patient demonstrates mild gait impairment and slight facial asymmetry.  Sensory examination is within normal limits.  Differential diagnosis includes stroke, multiple sclerosis, and cerebral palsy.  MRI brain showed evidence of small vessel disease.  Treatment plan includes physical therapy to improve muscle strength and coordination, occupational therapy for adaptive strategies, and medication management for risk factor modification including blood pressure and cholesterol control.  Patient is able to ambulate with a cane.  Prognosis is fair with expectation for continued improvement.  ICD-10 code I69.82 I69.89 will be used, along with appropriate CPT codes for evaluation and management and therapy services.