Wiki abdominal exam documentation element

[Sharee Luckeydoo]

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

 

[ARCPC9491]

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.