|
#1
07-02-2010, 03:51 AM
|
|||
|
|||
Physical Exam
What is the Extent of Physical Exam here:
Vitals: Height: 6’0” Weight: 160 Physical Examination: Patient is alert, appropriate, and comfortable. Patient holds a normal gaze. Pupils are round and reactive. Gait is normal. Skin is intact. No rashes, abrasions, contusions, or lacerations. No venous stasis. No pulses. No varicosities. No dyspnea. Reflexes are normal patellar. No clonus. Knee: Range of motion is apprximatly from 5 to 100 degrees. Pain with motion. No localized pain. Negative mechanical findings. There is effusion. Patella is tracking well. No tenderness. Patient feels pain especially when taking stairs or squatting. Hip: Exam is unremarkable. Normal range of motion, flexion approximately 105 degrees, extension approximately 10 degrees, abduction approximately 25 degrees, adduction approximately 30 degrees, internal rotation approximately 30 degrees, external rotation approximately 30 degrees. Neck: Neck is supple. No JVD. 
|
|
#2
07-02-2010, 12:42 PM
|
|||
|
|||
|
Detailed
Detailed per 1995 guidelines.
F Tessa Bartels, CPC, CEMC
|
|
#4
07-09-2010, 02:01 PM
|
|||
|
|||
|
Neck is NOT an organ system
Per the 1995 guidelines for a comprehensive exam you need to document 8 of the following 12 systems:
Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitoruinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic/Immunological "Neck" is NOT one of the organ systems. By the way ... just looking at this documentation I shake my head "no pulses" Really? No pulse at all? F Tessa Bartels, CPC, CEMC
|
|
#5
07-09-2010, 02:22 PM
|
||||
|
||||
|
Tessa,
You crack me up... 
__________________
Rebecca CPC, CPMA, CEMC Your click COUNTS... http://www.thebreastcancersite.com/c...faces?siteId=2 CLICK to give FREE mammograms!
|
|
#6
07-09-2010, 02:42 PM
|
|||
|
|||
|
Well ... it's Friday afternoon
Quote:
Tessa
|
|
#8
07-15-2010, 06:28 AM
|
||||
|
||||
|
I can't say I agree with your view...
Dyspnea by definition=difficult or labored respiration. This can be visually ascertained by the physician. I would not apply this exam statement to neck. This would follow under Respiratory (97 DG)... "assessment of respiratory effort" thus able to use this statement under respiratory for the 95's; or at least, I would.
__________________
Rebecca CPC, CPMA, CEMC Your click COUNTS... http://www.thebreastcancersite.com/c...faces?siteId=2 CLICK to give FREE mammograms!
|
|
#9
07-15-2010, 10:57 AM
|
|||
|
|||
|
pls review my post again, i counted it under respiratory only.
Quote:
__________________
Thanks, Jagadish, CCS-P, CPC
|
