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Wiki abdominal exam documentation element

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Sharee Luckeydoo

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Hello everyone,
The question is, is it appropriate to give credit (bullet) for the abdomen palpation portion if the physician states "abdomen soft" only?
Thank you,
Sharee
 
I wouldn't. Maybe if it stated "soft and nontender" I definitely would. Maybe you should query the provider.

The examination of abdomen bullet states "notation of presence of masses or tenderness" soft is nice, but doesn't quite fit.
 
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