m.matos@chcfl.com
Contributor
Hi,
In reviewing the exams to assess the level or care I am having a hard time determining when i should count the findings in the lungs as an affected area/system (outside of dx related to respitory). How are we to determine what indirect systems or areas are to be considered affected by the pts conditions.
For example: pt presents for f/u on HTN, DM, Hyperlipidemia and as part of the exam the lungs state " clear to auscultation bilaterally, good air entry bilaterally, no wheezes/rhonchi/rales".
Per the '95' guidelines we have it states: 2 to 7 areas of systems (4 findings in affected system(s); total of 8 or more findings over all.
I am unsure as to whether or not to consider the lungs as an affected system.
In reviewing the exams to assess the level or care I am having a hard time determining when i should count the findings in the lungs as an affected area/system (outside of dx related to respitory). How are we to determine what indirect systems or areas are to be considered affected by the pts conditions.
For example: pt presents for f/u on HTN, DM, Hyperlipidemia and as part of the exam the lungs state " clear to auscultation bilaterally, good air entry bilaterally, no wheezes/rhonchi/rales".
Per the '95' guidelines we have it states: 2 to 7 areas of systems (4 findings in affected system(s); total of 8 or more findings over all.
I am unsure as to whether or not to consider the lungs as an affected system.