I am so curious what others would say about the Exam level for this documentation (using 1995 guidelines). Established patient seen for f/u of kidney stones - EPF, DETAILED or COMPREHENSIVE exam??
Constitutional: General appearance: well-developed. Level of distress: NAD
Head: normocephalic and atraumatic
Eyes: Lids and conjunctivae: Non-injected, Sclerae: non-icteric
ENMT: Ears: external ears normal, Nose: external nose normal, Oropharynx: moist mucous membranes
Neck: Supple and no masses
Lungs: Respiratory effort: no dyspnea. Auscultation: CTA bilateral air movement present
Cardiovascular: Heart auscultation: normal S1 and S2, no rubs or murmurs
Abdomen: Bowell sounds: normal, soft, non-distended and no tenderness
Musculoskeletal: Extremities: no cyanosis or edema
Skin: warm and dry
Psychiatric: good judgement. Mental Status: normal mood and affect
I'll share what I came up with & why, after I get some other opinions.
Thank you!
Lora
Constitutional: General appearance: well-developed. Level of distress: NAD
Head: normocephalic and atraumatic
Eyes: Lids and conjunctivae: Non-injected, Sclerae: non-icteric
ENMT: Ears: external ears normal, Nose: external nose normal, Oropharynx: moist mucous membranes
Neck: Supple and no masses
Lungs: Respiratory effort: no dyspnea. Auscultation: CTA bilateral air movement present
Cardiovascular: Heart auscultation: normal S1 and S2, no rubs or murmurs
Abdomen: Bowell sounds: normal, soft, non-distended and no tenderness
Musculoskeletal: Extremities: no cyanosis or edema
Skin: warm and dry
Psychiatric: good judgement. Mental Status: normal mood and affect
I'll share what I came up with & why, after I get some other opinions.
Thank you!
Lora