Comprehensive Exam

clbarry8033

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I was just wondering if you guys would count this as a comprehensive exam in 95 guidelines.

CC: Abdominal pain.

Vital signs: Stable. He is afebrile.
Cardiovascular: Reveals good respiratory effort. Pulses are regular.
Abdomen: Soft. RUQ pain to palpation.
Extremities: No cyanosis, clubbing, or edema. No calf tenderness.
General: He is alert and oriented x3. No apparent distress.
HEENT: Pupils are equally round and reactive to light. Nares are patent.
Neck: Trachea is midline.

I was thinking there were 8 OS. Aren't we supposed to put exam elements into the correct organ system?

Constitutional: Vitals
Cardiovascular: Pulses
Respiratory: Respiratory effort
GI: RUQ pain to palpation
Musculoskeletal: Extremities
Psych: A&O x3
Eyes: Pupils equal
ENT: Nares are patent/trachea is midline

Thank you for your help!
 

Jennifer Turner

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Local Chapter Officer
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This would not be a comprehensive exam. There are not enough elements to support a comprehensive exam. It would be more "detailed".

PF: 1 OS (system related to problem)
EPF: 2-4 OS
Detailed: 5-7 OS
Comprehensive: 8 or more OS

Does this makes sense? Hope this helps.
 

wynonna

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exam elements

I was just wondering if you guys would count this as a comprehensive exam in 95 guidelines.

CC: Abdominal pain.

Vital signs: Stable. He is afebrile.
Cardiovascular: Reveals good respiratory effort. Pulses are regular.
Abdomen: Soft. RUQ pain to palpation.
Extremities: No cyanosis, clubbing, or edema. No calf tenderness.
General: He is alert and oriented x3. No apparent distress.
HEENT: Pupils are equally round and reactive to light. Nares are patent.
Neck: Trachea is midline.

I was thinking there were 8 OS. Aren't we supposed to put exam elements into the correct organ system?

Constitutional: Vitals
Cardiovascular: Pulses
Respiratory: Respiratory effort
GI: RUQ pain to palpation
Musculoskeletal: Extremities
Psych: A&O x3
Eyes: Pupils equal
ENT: Nares are patent/trachea is midline

Thank you for your help!

Answer: For Comprehensive you need 8 or more body/organ systems examined. Exam can be palpation (touching) or questioning, such as in psychiatric complaints. For a body/organ system to count, for 1995 guidelines, each system has to have at least 2 points documented. Only one point doesn't make it a system. Also if abdominal pain is counted in Chief complaint in history section, it cannot be counted again in Exam.
 
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