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Wiki Pap Smear Procedure note

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KoBee

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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
 
KoBee said:
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
Click to expand...
Pap done is sufficient, but not great documentation. Your sending in the smear to the lab and getting back a result with confirm it was done.
 
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