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Wiki Exam requirements

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ANWALKER

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In the physical exam component does the physician literally have to do all the work? For example can he state "reviewed vitals from the triage notes" and then paste them into his exam and get credit? I have been trained that the physician has to be "hands on" in the exam component, no information can be reviewed. What ever the answer is there documentation on this issue?

Thank you!
 
ANWALKER said:
In the physical exam component does the physician literally have to do all the work? For example can he state "reviewed vitals from the triage notes" and then paste them into his exam and get credit? I have been trained that the physician has to be "hands on" in the exam component, no information can be reviewed. What ever the answer is there documentation on this issue?

Thank you!
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for documentation of vital signs as an exam component a statement stating that the provider reviewed them would count as a bullet for 97 or constitutional for 95. All other components must be completed in a "hands on" manner.
 
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