Wiki 1995 Guidelines

[livininthegray]

I have a question about the body areas/organ systems examination part of the 1995 Guidelines. The body area shows
Head,including the face
Neck
The organ system shows
Ears, nose, mouth and throat
Do you give credit to body and organ systems (without double dipping) or do you pick one and give credit to that one only?
I am confused on the Neck(body area)/ throat(organ system) part, my doctor will state something like,
NECK: Supple, Thyroid gland not enlarged. Would that not be counted in the
Hematologic/lymphatic/immunologic organ system part of the exam?
I am very,very new at this..

Livininthegray

 

[FTessaBartels]

1995 is Vague

The 1995 guidelines are quite vague and do NOT do a good job of identifying what they mean.

I usually look at the 1997 guidelines to see where something will fall (Yes, I know, you are using 1995 - so am I. But 1997 is so specific it helps to clarify.)

So using your examples: my doctor will state something like,
NECK: Supple, Thyroid gland not enlarged.

1997 lists the Thyroid under NECK ... so this entire statement would just count as Neck (a body area)

If your physician had also mentioned "No lymphadenopathy" ... per 1997 this would be under Lymphatic system.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[Kstrobel]

1995

I count the throat (ears, nose, mouth and throat) when the throat is mentioned as sore throat, pharyngitis etc.
If the lymph glands, thyroid etc. are described, I count the lymphatic system.
Hope theis helps.