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Wiki how would you score this?

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bedforak1

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Would you give the provider a EPF or Detailed exam for this?

Vital Signs and Measurements:
Temp 97.5
Peripheral Pulse 72 BPM
Systolic BP 197 mmHG
Diastolic BP 80mmHG
Resp Rate 16RR
O2 Sat 89%

Lab Results
Blood Glucose 213 mg/dL
 
This to me is actually only a Problem Focused Exam. I am only seeing one organ system (constitutional) being represented here. You have 5 of the 7 vital signs however the status of them is not mentioned. This would not be considered a detailed exam. Vital signs are or should be routine on almost every encounter.

Hope this helps,
Andrew
 
I too agree with PF - vital signs do not qualify in any of the organ systems, i.e. BP values cannot be used for cardiovascular.
 
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