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Wiki Physical Exam

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sparkles1077

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I have a teaching physician scenario where the fellow documents the MDM only. The attending does document a compliant attestation and indicates he saw and examined the patient with the resident. The findings of the exam are not documented by the fellow or attending. I do see this portion in the MDM and am wondering if others would consider this a physical exam?:

No e/oGIB - stool in bag is light brown. NGT with minimal blood tinged output, <20cc in 24h.

Thank you so much for your help
 
pjmissall

I was always told if it is not dictated then it didn't happen. Either the provider or the attendant has to go back and do an addendum to the note.
 
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