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Wiki opinion on exam elements (95 guidelines)

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kredd

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Hi all. I'm having a disagreement with a co-worker about how to count things in exam (using 95 guidelines). if I could get your opinion regarding the following exams I would really appreciate it.

Gen: NAD, AAOx3; HEENT: 0 scleral icterus, PERRL mildly dry mucous membranes; Pulm: CTA B/L, 0 wheezes, rales, ronchi, decreased air movement in lower lung fields; CV: RRR normal s1,s2, no JVD; Abd: +BS, soft, NT ND, 0 hepatomegaly; LE: WWF, 0 edema; Psych: appropriate affect and memory, insight limited; skin no rashes, warm and dry with normal turgor

Gen: NAD/ vitals recorded; HEENT: MMM; Cards: RRR, +s1s2; pulm: decreased BS diffuse B/L; Abdomen: Soft nontender; ext: no LE edema; neuro: nonfocal; psych: appropriate affect

thank you in advance for any and all opinions regarding these.
 
Please tell me what YOU think first

Before I tell you what I think, please tell me what YOU think first, and why there is controversy about how you assess this.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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