Comprehensive Exam

shanamarie

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Hello, Looking for some opinions on if this qualifies for a comprehensive exam by 97 guidelines?

General observation finds patient to be pleasant and appearing to be in good general health. There is no acute distress. Auscultation reveals a regular rate and rhythm without murmur. Patient is oriented, fluent and follows commands without difficulty. Attention and concentration are normal. Memory, fund of knowledge and insight are good. Visual fields are full. Optic discs sharply marginated. Pupils are equal. Extraocular movements are full without nystagmus or diplopia. Facial sensation is symmetric. No facial paresis. Hearing is symmetric for finger rub. Tongue and palate are midline. Shoulder shrug strength is normal. No tremor. Motor tone, bulk and strength are normal throughout the upper and lower extremities. Deep tendon reflexes are symmetrically depressed in the arms and legs, absent at the ankles. Plantar responses are flexor. There is diminished vibratory sensation at the ankles and toes. Coordination is normal. Gait is normal. Can toe and heel walk. There is some difficulty with tandem walking. Romberg is negative. The feet are warm and well perfused. There is no plantar tenderness. Also, there is no hyperpathia to light touch over the feet. 3 vital signs are also documented in the note.
 

Pam Brooks

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You don't give your specialty, so but it looks like this might be Neurology?
General appearance is noted, with three vital signs. The Constitutional exam is a shaded box in the 1997 Neuro guidelines, and was met.

Under eyes, I see the exam of pupils and irises, as well as the ophthalmic exam of optic discs. This is also a shaded box, so this meets the documentation criteria.

Under Cardiovascular, auscultation is noted, as is exam of peripheral vascular system (I counted the warm/perfused feet), but I don't see any notation of an exam of carotids, mentioning bruits and/or pulse sound. However, this is an unshaded box, so provider needs to document only one bullet, and he/she did two.

Under MS, gait and station were noted. There is an assessment of muscle strength in upper and lower extremities as well as tone. This is a shaded box, and was met.

Under Neuro, there's mention or orientation, memory, attention/concentration, fund of knowledge and language (following commands).

I see that the provider examined 2nd cranial nerve (visual acuity), the 3rd, 4th and 6th (pupils, eye movements), the 5th (facial sensation), the 7th, (facial symmetry), the 8th, (hearing assessment). The 9th cranial nerve should have discussed palate movement, although the documentation indicates that the tongue and palate are midline. I would accept that as being a normal finding, but it's a documentation improvement opportunity.
The 11th cranial nerve is mentioned with the shoulder shrug and the 12th again with the tongue being indicated as normal.

Sensation is examined (via ankles/toes), as is DTR and coordination. The neurological exam box is shaded, and each bullet was met, with my recommendation for 9th cranial move, discussing spontaneous or reflux palate movement, and the 12th cranial nerve which should indicate exam of tongue protrusion.

I'd consider this a comprehensive Neurological exam with the 1997 guidelines. I wish this doctor would come and train my neurologists!
 

shanamarie

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Messages
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Location
Eagan
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You don't give your specialty, so but it looks like this might be Neurology?
General appearance is noted, with three vital signs. The Constitutional exam is a shaded box in the 1997 Neuro guidelines, and was met.

Under eyes, I see the exam of pupils and irises, as well as the ophthalmic exam of optic discs. This is also a shaded box, so this meets the documentation criteria.

Under Cardiovascular, auscultation is noted, as is exam of peripheral vascular system (I counted the warm/perfused feet), but I don't see any notation of an exam of carotids, mentioning bruits and/or pulse sound. However, this is an unshaded box, so provider needs to document only one bullet, and he/she did two.

Under MS, gait and station were noted. There is an assessment of muscle strength in upper and lower extremities as well as tone. This is a shaded box, and was met.

Under Neuro, there's mention or orientation, memory, attention/concentration, fund of knowledge and language (following commands).

I see that the provider examined 2nd cranial nerve (visual acuity), the 3rd, 4th and 6th (pupils, eye movements), the 5th (facial sensation), the 7th, (facial symmetry), the 8th, (hearing assessment). The 9th cranial nerve should have discussed palate movement, although the documentation indicates that the tongue and palate are midline. I would accept that as being a normal finding, but it's a documentation improvement opportunity.
The 11th cranial nerve is mentioned with the shoulder shrug and the 12th again with the tongue being indicated as normal.

Sensation is examined (via ankles/toes), as is DTR and coordination. The neurological exam box is shaded, and each bullet was met, with my recommendation for 9th cranial move, discussing spontaneous or reflux palate movement, and the 12th cranial nerve which should indicate exam of tongue protrusion.

I'd consider this a comprehensive Neurological exam with the 1997 guidelines. I wish this doctor would come and train my neurologists!
Thank you! I appreciate your review.
 
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