documentation improvement

  1. H

    Physical Exam Documentation help

    I'm an internal auditor and I have run into some exam documentation that I have not encountered before. The physician is using "denies" within the exam section which to me is more like ROS documentation, not physical exam. Musculoskeletal: Wrists Denies swelling, denies tenderness Ankles...
  2. J

    Documentation Improvement - CRC exam

    Good Afternoon, I have attempted my CRC exam twice and have come really, really close. I keep falling "short" in the area of "Documentation Improvement" I have the study guide (well, partially. Chapters 6-11) Is there any "hope for me"? I have read all the materials I have and all of my scores...