Hi,
I am working with my providers to help them better understand compliant documentation, in particular with the exam bullets.
Please let me know what you think about the bullets on this note. I came up with 21 total.
Vital Signs (1 Bullet)
(Initials) ac, BP 110/72, Cuff size adult, HR 112, RR 16, Temp 99.7, Site oral, Ht 54.75, Wt 128, BMI 30.02, BMI % 98.52, Oxygen sat % 99
General Exam:
General Appearance Pleasant, NAD, Well-developed, well-nourished, No Resp Distress, AOX3, overweight. (1 bullet for const, 1 bullet for resp, 1 bullet for psych)
HEENT External ear unremakable, Ear canals clear, No rhinorhea. (3 bullets)
ORAL CAVITY: no lesions, unremarkable exam, no tonsillar exudate, mucosa pink. (1 bullet)
NECK: supple, no thyromegaly, no lymphadenopathy. (1 bullet for neck exam)
CHEST: normal quiet breathing. (included under lungs - no point here)
HEART: RRR, normal S1S2, no murmurs, regular rate. (1 bullet)
LUNGS: clear to auscultation bilaterally, no wheezes or crackles. (1 bullet)
ABDOMEN: soft, NABS, NT, No HSM. overweight. (1 bullet abd exam, 1 bullet liver/spleen)
SKIN: Normal appearance, no rash. (1 bullet)
EXTREMITIES: no clubbing, no edema, sensation normal, normal ROM, motor + reflexes normal. (1 bullet for m/s digits, 1 bullet cardio - edema, 1 bullet neuro - sensation, 1 bullet - ROM)
PSYCHIATRIC: odd affect/ laisse faire. (1 bullet)
MUSCULOSKELETAL nml gait, nml ROM . (no score)
BACK: normal ROM of spine, no midline tenderness. (1 bullet m/s - exam of back)
NEUROLOGIC EXAM: sensory & motor WNL, DTR 2 plus, DTR 2 + bilat, Romberg test negative. (already counted one for sensation under Extremities, 1 bullet DTR)
Thanks for your thoughts.
Arrana Ashton, CPC
I am working with my providers to help them better understand compliant documentation, in particular with the exam bullets.
Please let me know what you think about the bullets on this note. I came up with 21 total.
Vital Signs (1 Bullet)
(Initials) ac, BP 110/72, Cuff size adult, HR 112, RR 16, Temp 99.7, Site oral, Ht 54.75, Wt 128, BMI 30.02, BMI % 98.52, Oxygen sat % 99
General Exam:
General Appearance Pleasant, NAD, Well-developed, well-nourished, No Resp Distress, AOX3, overweight. (1 bullet for const, 1 bullet for resp, 1 bullet for psych)
HEENT External ear unremakable, Ear canals clear, No rhinorhea. (3 bullets)
ORAL CAVITY: no lesions, unremarkable exam, no tonsillar exudate, mucosa pink. (1 bullet)
NECK: supple, no thyromegaly, no lymphadenopathy. (1 bullet for neck exam)
CHEST: normal quiet breathing. (included under lungs - no point here)
HEART: RRR, normal S1S2, no murmurs, regular rate. (1 bullet)
LUNGS: clear to auscultation bilaterally, no wheezes or crackles. (1 bullet)
ABDOMEN: soft, NABS, NT, No HSM. overweight. (1 bullet abd exam, 1 bullet liver/spleen)
SKIN: Normal appearance, no rash. (1 bullet)
EXTREMITIES: no clubbing, no edema, sensation normal, normal ROM, motor + reflexes normal. (1 bullet for m/s digits, 1 bullet cardio - edema, 1 bullet neuro - sensation, 1 bullet - ROM)
PSYCHIATRIC: odd affect/ laisse faire. (1 bullet)
MUSCULOSKELETAL nml gait, nml ROM . (no score)
BACK: normal ROM of spine, no midline tenderness. (1 bullet m/s - exam of back)
NEUROLOGIC EXAM: sensory & motor WNL, DTR 2 plus, DTR 2 + bilat, Romberg test negative. (already counted one for sensation under Extremities, 1 bullet DTR)
Thanks for your thoughts.
Arrana Ashton, CPC