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musculoskeletal exam elements

sullivak

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Question - In 1997 multi-system exam, do all of the following bullets

- inspection and/or palpation with notation...
- assessment of range of motion....
- assessment of stability with notation of any dislocation...
- assessment of muscle strength and tone....

have to be documented for the one or more of the following six areas 1)head and neck; 2) spine, ribs and pelvis 3) right upper extremity.............???

My suspicion is no, but I just want to make sure.
 

btadlock1

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Question - In 1997 multi-system exam, do all of the following bullets

- inspection and/or palpation with notation...
- assessment of range of motion....
- assessment of stability with notation of any dislocation...
- assessment of muscle strength and tone....

have to be documented for the one or more of the following six areas 1)head and neck; 2) spine, ribs and pelvis 3) right upper extremity.............???

My suspicion is no, but I just want to make sure.
In context, that guideline says:
"Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; 6) left lower extremity. The examination of a given area includes:
-Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions.
-Assessment of range of motion with notation of any pain, crepitation or contracture
-Assessment of stability with notation of any dislocation (luxation), subluxatoin or laxity.
-Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.

As a good example, our EMR system lists Exam elements out by organ system. Occasionally, I see a note that says something along the lines of:
"Musculoskeletal: Normal ROM, normal strength"

And I don't count it. Why? Because it's not clear what the doctor is talking about. Did he examine the entire body? Or was is just one arm/leg - or both arms/legs?

I interpret that guideline to mean, that each bullet point for an aspect of the examination, must directly correspond with at least one of those areas, in order to count for credit. If the area's not documented, then it's impossible to know what was examined. Not documented, Not done.

Hope that helps! ;)
 

sullivak

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Thanks for the response, Brandi. That is helpful.

Along the same lines - I often see "musculoskeletal- overall - no deformity".
I haven't been counting that as a bullet for 1997 multisystem musculoskeletal because it doesn't seem to fit the criteria at all. (Honestly, I'm not even very comfortable counting it for 1995).
 
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