1997 Exam bullets

Cbo1815

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Question regarding acceptable response for 1997 guidelines for an exam-would these count as bullets?

Musculoskeletal: No deformity
Gastrointestinal: No organomegaly
Psych : Cooperative and alert; normal mood and effect

Any help is appreciated! :)
 

Cbo1815

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Thanks for your response :)

The "No deformity" is the one I'm struggling with.
 
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sullivak

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Does anyone have an answer for the "musculoskeletal no deformity"? I'm struggling with this as well.
Thanks.
 

sullivak

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This is what I've been thinking about this issue -

For a musculoskeletal exam in a multi-system exam for 1995, pretty much whatever the physician says would be counted so something like “musculoskeletal: overall no deformity” would be counted as musculoskeletal exam.

However, in 1997 guidelines, if the physician says “musculoskeletal: overall no deformity,” this shouldn’t count. Per 1997 guidelines, mention of gait, back exam, assessment of muscle strength and tone, palpation of digits, head/neck exam, spine/rib/pelvic exam, upper extremity exams, and lower extremity exams are counted. There is no mention of “overall”.

As for the "no organomegaly" for GI issue, I think this might be okay. One of the bulleted elements is "examination of liver and spleen" and this is what they are talking about when they say no organomegaly. Again, this documentation is far from ideal.
 

sullivak

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Oh, and for the psych exam-
I think this would count for two elements - "orientation to time, place and person" and "mood and affect".
 
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