Wiki 1955 exam example from ED (child )

[kviolet]

Below is a copy of Dr X pt’s exam:
I found 7 organ systems.
am I correct ?

Physical Exam:
· Gen: Alert WDWN NAD No Pallor Moist Mucosa (1)
· Head: NCAT (body area)
· Eyes: Conj/lids within normal limits (2)
· Neck: No Meningismus No Adenopathy (body area)
· Lungs: CTA No wheezes/rhonchi/rales No retractions (3)
· CV: Normal Perfusion Peripheral Pulses Normal RRR No murmurs/gallops/rubs (4)
· GI: Soft Non-tender – point to body areas “abdomen” not Organ system “GI” because in order to get GI credit it should have more documentation for example mention about HSM or hernias
· Skin: right great toe - base of 1st MTP with blister that then leads into a dark discolored toe, nail is everted at its tip, + erythema proximal to the MTP joint. no tenderness. (5)
normal gait (6) neuro no fluctuance. no induration.
· Extrem: FROM Capillary refill within normal limits Peripheral pulses within normal limits (7)

Belowis a respond from the ED doctor :

Thanks - but this really can’t be accurate- this is an interpretation/understanding problem:
Head and Neck should be considered an organ system just the same as “GEN: WDWN NAD No Pallor Moist Mucosa”

HEAD: includes organ systems neuro and musculoskeletal (bones): so NCAT (Normocephalic, Atraumatic)- means that the skull bones were intact, head size was normal ( for example no microcephaly or macrocephaly which might indicate a neurological condition)

Neck- includes organ systems such as NEURO and LYMPHATIC: so that
“Neck: No Meningismus No Adenopathy”- MUST be interpreted- with that in mind- “no meningismus” means that there were no neurological signs of infection and “no adenopathy” means that there were no local signs of lymphatic infection of the throat, ears, etc).

Please clarify again why things like Head and Neck should be excluded.
Also for GI- when the doctor’s write “soft, non-tender”- it is UNDERSTOOD that refers to abdomen. It should be entirely sufficient to write abdomen-soft, non-tender ( for getting credit for 1 body part in 1 organ system).
Unless you are saying that you need more than 1 element per organ system.

thanks



How should I reply ? Thanks for any help!!!


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[jdibble]

Below is a copy of Dr X pt’s exam:
I found 7 organ systems.
am I correct ?

Physical Exam:
· Gen: Alert WDWN NAD No Pallor Moist Mucosa (1)
· Head: NCAT (body area)
· Eyes: Conj/lids within normal limits (2)
· Neck: No Meningismus No Adenopathy (body area)
· Lungs: CTA No wheezes/rhonchi/rales No retractions (3)
· CV: Normal Perfusion Peripheral Pulses Normal RRR No murmurs/gallops/rubs (4)
· GI: Soft Non-tender – point to body areas “abdomen” not Organ system “GI” because in order to get GI credit it should have more documentation for example mention about HSM or hernias
· Skin: right great toe - base of 1st MTP with blister that then leads into a dark discolored toe, nail is everted at its tip, + erythema proximal to the MTP joint. no tenderness. (5)
normal gait (6) neuro no fluctuance. no induration.
· Extrem: FROM Capillary refill within normal limits Peripheral pulses within normal limits (7)

Belowis a respond from the ED doctor :

Thanks - but this really can’t be accurate- this is an interpretation/understanding problem:
Head and Neck should be considered an organ system just the same as “GEN: WDWN NAD No Pallor Moist Mucosa”

HEAD: includes organ systems neuro and musculoskeletal (bones): so NCAT (Normocephalic, Atraumatic)- means that the skull bones were intact, head size was normal ( for example no microcephaly or macrocephaly which might indicate a neurological condition)

Neck- includes organ systems such as NEURO and LYMPHATIC: so that
“Neck: No Meningismus No Adenopathy”- MUST be interpreted- with that in mind- “no meningismus” means that there were no neurological signs of infection and “no adenopathy” means that there were no local signs of lymphatic infection of the throat, ears, etc).

Please clarify again why things like Head and Neck should be excluded.
Also for GI- when the doctor’s write “soft, non-tender”- it is UNDERSTOOD that refers to abdomen. It should be entirely sufficient to write abdomen-soft, non-tender ( for getting credit for 1 body part in 1 organ system).
Unless you are saying that you need more than 1 element per organ system.

thanks



How should I reply ? Thanks for any help!!!


Edit Post Reply With Quote

I am assuming you are looking at 1995 guidelines (and the heading was a typo).

For the physical exam, the heading titles don't matter as much as what is documented in the content. This is what we instruct our doctors to document for the above exam:

General: Under this section the documentation of at least 3 vital signs is usually what is required. General appearance is extra. Also, if he had documented here Alert and oriented x3 here, that could have counted towards Psych!

Head: The definition of normocephalic: adjective Referring to a head of normal shape and of normal size for the person’s age. I had questioned this too and was advised by Novitas (our MAC) that this statement is not counted as a "system". For the documentation to count towards systems under this heading, I would look for a statement about HEENT - eyes, ears, nose, etc. ass these are the systems of the head.

Neck: While that is a body system, if the doctor documents findings in regards to the lymph nodes or the thyroid, that is counted under the Hem/Lymphatic system. The statement here of no adenopathy qualifies.

Lungs, CV: They are OK.

GI: soft, non-tender would count towards this system.

Skin, Neuro: These are good

Extremities: The documentation here would not be counted towards Musculoskeletal, which is the organ system, as what is documented refers to the cardio-vascular system. Documentation of range of motion, joint pain, etc. would be needed to count this as MS.

So, for this exam I would give credit for Eyes, Lymphatic, Lungs, CV, Skin, Neuro, and GI, so I still get 7, just different systems.

Hope that helps.