Wiki Exam Documentation: GI vs. Abdomen

[imaginethat23]

Good morning!

I'm trying to get some feedback on how several of my providers document findings in their Exams. Being somewhat new to this, I'm questioning whether clarification is needed or if the documentation would suffice.

Specifically, I'm questioning the GI system notes and feel that the providers are interchanging "GI" with "Abdomen". This is an example of what I see:

Gastrointestinal: soft, non-tender

I've searched a lot of resources and I've seen "Abdomen: soft, non-tender" and "Gastrointestinal: Abdomen is soft, non-tender" but nothing that matches what I'm seeing. Personally, I feel they should be specifying Abdomen when notating that information under the GI system, but maybe I'm being too picky?

Any thoughts/opinions would be greatly appreciated!

 

[jvanek82]

Good morning!

I'm trying to get some feedback on how several of my providers document findings in their Exams. Being somewhat new to this, I'm questioning whether clarification is needed or if the documentation would suffice.

Specifically, I'm questioning the GI system notes and feel that the providers are interchanging "GI" with "Abdomen". This is an example of what I see:

Gastrointestinal: soft, non-tender

I've searched a lot of resources and I've seen "Abdomen: soft, non-tender" and "Gastrointestinal: Abdomen is soft, non-tender" but nothing that matches what I'm seeing. Personally, I feel they should be specifying Abdomen when notating that information under the GI system, but maybe I'm being too picky?

Any thoughts/opinions would be greatly appreciated!

When scoring the E/M exam you can use the information either under headings Abdomen or GI to count towards your systems. If it states Gastrointestinal as the header, with soft, non-tender it means the same as abdomen non-tender. The abdomen contains the gastrointestinal organs.

Hope that helps.