Tessa,
"HENT: Normocephalic - NO bullets under 1997"
Out of curosity, why wouldn't you count this statement under M/S--->head/neck
Head/Neck-Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions
Normocephalic=refers to an individual whose head and major organs associated with the head are in a normal condition without significant abnormalities.
I never considered that...but would it be safe to assume that he's referring to the joints, bones, and muscles, specifically, or would he need to elaborate?
I had been
leaning towards counting it as 'External inspection of ears and nose', because if his HENT is without significant abnormalities, it would be logical to say that their ears and nose were anatomically 'normal', too. I'm just not sure if it's detailed enough to meet the requirements of either
bullet, though. If I could count it under M/S, could I also count it under ENT, under the same premise?
And let me ask you guys about this one...(Forgive me for thinking out loud, here...
)
Would you give credit under 'ascultation of heart', for the statement "
Normal rate, regular rhythm" (by itself)? I'm okay with giving credit when they
also say "no murmur", but it's not always there. My problem with the shorter statement is: is that something that you could determine without actually
listening to their heart; or could they make that assessment by reviewing the vital sign info (BP, pulse rate and regularity)?
The word "
rhythm" is what's really tripping me up - if I understand the word 'rhythm' correctly, it's the consistency of the beat over a given time frame. The easiest way to detect it would be hearing it, but it seems to me, like you also
feel the rhythm by feeling their pulse, which is not a bullet. So should he have to actually say something to indicate that he listened to it (like, 'no murmur'), or am I asking for too much?
I know I'm being really anal about these guidelines, but I'm trying to audit these charts the way that an RAC or OIG auditor might, and I've got
so much to go over with these providers about their documentation already, that I don't want to critique them on anything that's not necessary. But I won't be doing anybody any favors by letting them think that some of these things are acceptable, either, if they're not. I just want to make sure I'm not out of line.