Wiki physical exam question

[ktominac]

I've been going back and forth with the other coders in the office as to what we can and can't count for organ systems in an example like this....

General- pleasant gentleman
Vital Signs-Temperature 36.5, heart rate 120, respiratory rate 16, blood pressure 151/112
HEENT- Head is normocephalic. There are no obvious sores or lesions noted. Skin is appropriate color. Sclera are white.
Respiratory- Lungs dim bases bilaterally, clear to auscultation.
Neck- No masses noted.
Cardiovascular- Heart S1, S2 noted. Regulare, tachycardic without any rubs or murmurs. JVD noted. No carotid bruits. +2 radial pulses
Abdomen- Soft, nontender, bowel sounds. HJR
Skin- No obvious rashes noted
Psych- A/O x3


Our main confusion is whether we can count no obvious sores or lesions for the ears, nose, and throat.
Any input will help!

 

[thomas7331]

I would not count it for ENT because the provider has not documented what was examined. The provider could be referring to the skin of the head, which would not be ENT - there's no way of knowing if it is not documented.