Wiki EHR secions "Exam" versus "Physical Exam"

[amexnikki23]

Specific EHR used is eClinicalworks but I am assuming most EHRs would have this. When the providers document their Exam portion of the encounter in the EMR, there is an "Exam" section and a "Physical Exam" section and usually both are marked up. What is the difference? When I am counting Body Areas versus Organ Systems in calculating EM elements, it sometimes gets sticky.

 

[LLovett]

I have never seen this before

I have worked with a lot of different EMRs, including eClinicalworks, but I have never seen 2 exam sections like you are describing. From a coding perspective the 2 terms, Exam and Physical Exam, are defining the same thing. When we say "exam" that is essentially the abbreviated version of "physical exam".

This sounds like a set up quirk or issue with this particular system. Not all EMRs are the same, even if they are from the same place. With most systems you get what you pay for and they have all kinds of add-ons and upgrades out there which will vary the options seen within each individual build.

The only rationale I can think of for having 2 separate exams would be if they have them set up to drive a leveling tool based on either 95 or 97 guidelines.
In that case there should one be 1 completed though, not both.

Sorry not much help,

Laura, CPC, CPMA, CPC-I, CANPC, CEMC

 

[amexnikki23]

Thanks. I can't seem to figure it out. In the "Exam" section it doesn't give all of the OS options, but in the "Physical Exam" section, it does. However the providers choose mostly everything from the "Exam" part and then choose the "add-ons" (like you said) when they have to add additional OS to meet higher level EM coding criteria. It probably is a 95/97 guidelines thing, but nevertheless, it drives me crazy trying to count BAs and OS as so many are repeated. Thanks again!

 

[jvanek82]

Specific EHR used is eClinicalworks but I am assuming most EHRs would have this. When the providers document their Exam portion of the encounter in the EMR, there is an "Exam" section and a "Physical Exam" section and usually both are marked up. What is the difference? When I am counting Body Areas versus Organ Systems in calculating EM elements, it sometimes gets sticky.

I am not sure about how your eClinicalworks is set up, but for our physicians, this is a template issue. Our system has separate templates set up for Cardiology Exam, Ortho Exam, General Exam, Physical Exam, etc. Each template is set-up with different information that automatically populates. Since your 2 templates have different information, the physicians may be picking both so that they can document everything they have done. For example, our Ortho will do the Ortho exam and then do part of the Physical Exam for each patient. The Cardiologists only use the Cardio Exam because they have it set up to include everything they need on the one template.

You may want to go over the templates with the doctors and whoever sets up your templates to see if they can create one template to include the elements of their usual exams.

 

[AprilSueMadison]

We have two separate sections like this. The physical exam for our patients (derm) is for the body check. The doctors check off all of the body systems they looked at. That way if they checked the arms, but didn't find anything suspicious, it is still noted.

The exam portion is for more specific information. So if they check the arms, it shows up in the physical exam, and then if they spot a lesion under EXAM it will show up as "R lower forearm - 1.3 cm ulcer, bleeding, purulent" and so on.

I agree with other posters that this sounds like a template issue. Instead of pulling from two separate sections, it sounds like it is pulling the same data.