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Wiki Exam documentation - When a child is being seen for cough

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sluke9

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I have a couple of situations that I need help with.

When a child is being seen for cough, fever, congestion and the Exam covers Vitals, Head, Eyes, ENT, Cardio, Respiratory, Abdomen, Musculoskelel, Skin, & Neuro as to whether you consider all areas as medically necessary and give a comprehensive exam?

On a respiratory exam what or how many points would you consider enough to make it an extended exam to qualify as a detailed level?

Thanks for any input!
 
Regarding the sick child: As a provider, I agree on the Vitals, Head, Eyes, ENT, Cardio, Respiratory, Abdomen, Skin, and neuro. It would depend on the condition of the child if the musculoskeletal would be medically necessary. Without the musculoskeletal, you would still have 8 systems which would qualify for a comp exam.

My take on an "extended respiratory exam" would be: "CTAB, no rales, rhonchi or wheezing. No accessory muscle use or retractions. Chest to percussion reveals no abnormalities".

I hope this helps!
 
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