Wiki Physical Exam - Question on the physical exam part of documentation

[jessica1974]

Question on the physical exam part of documentation. I normally use the 95 guidelines because my physicians seem to be more in tune with them. My question is can you use body systems & organ systems or just one. For instance an exam might look like this:

General:awake, alert etc
Head: atraumatic etc
Neck: no carotid bruit, jvd etc
Cardiovascular: positive S1, S2, regular rate etc
Lungs: symmetrical expansion, clear etc
Abdomen: positive bowel sounds etc
Extremities: no cyanosis, clubbing or edema
Neurologic: cranial nerves are intact. Sensation intact

Would you have to pick the body systems or the organ systems? While he actually has all 8 they are not specific to body or organ. I want to make sure that I am giving him the correct level. I will typically go with the one he has the most bullets on.

Thanks for the help.

 

[MikeEnos]

You are allowed to mix and match body areas and/or organ systems for an Expanded Problem Focused or Detailed exam, but to get a Comprehensive exam using the '95 Guidelines you must have findings of organ systems only. Body areas don't count. I'm not exactly sure why.

Keep in mind that just because they labeled it as a body area, it might be more advantageous to count it as an organ system depending on the finding. For example - Neck: No JVD might be counted as Cardiovascular instead of neck, or Neck: No lymphadenopathy might be counted as Hem/Lymph instead of neck.