If a provider just documents " pap was done" or " pap done" during a annua gyn exam visit, is that sufficient to code a pap smear? shouldn't there be some sort of procedure note? or is it to assume its in the pelvic exam
example: I see a pelvic exam but i dont see the pap done
Physical Exam
There were no vitals taken for this visit.
GEN: NAD
NECK: Supple, no masses palpated.
BREASTS: No masses, nipple discharge, erythema. No axillary, supra-, or infraclavicular adenopathy.
LUNGS: CTA bilaterally
COR: RRR without appreciable murmur
ABDOMEN: Soft, NT/ND. No masses. No organomegaly.
PELVIC:
BLADDER: Non-tender and without palpable fullness or mass
BUSV: No lesions
VAGINA: Normal epithelium without lesions.
CERVIX: No gross lesions, CMT, or discharge
UTERUS: Normal size, mobile, nontender
ADNEXA/PARAMETRIA: No masses or nodularity palpated, nontender
RECTAL: Deferred
EXT: No LE edema or calf tenderness
Impression
Well woman exam
Plan
Check pap
SBE instructed
Advise annual clinical breast and pelvic exams
example: I see a pelvic exam but i dont see the pap done
Physical Exam
There were no vitals taken for this visit.
GEN: NAD
NECK: Supple, no masses palpated.
BREASTS: No masses, nipple discharge, erythema. No axillary, supra-, or infraclavicular adenopathy.
LUNGS: CTA bilaterally
COR: RRR without appreciable murmur
ABDOMEN: Soft, NT/ND. No masses. No organomegaly.
PELVIC:
BLADDER: Non-tender and without palpable fullness or mass
BUSV: No lesions
VAGINA: Normal epithelium without lesions.
CERVIX: No gross lesions, CMT, or discharge
UTERUS: Normal size, mobile, nontender
ADNEXA/PARAMETRIA: No masses or nodularity palpated, nontender
RECTAL: Deferred
EXT: No LE edema or calf tenderness
Impression
Well woman exam
Plan
Check pap
SBE instructed
Advise annual clinical breast and pelvic exams
