Physical exam

Jlokloski

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In the guidelines under documentation of the examination it states "A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area (s) or asymptomatic organ system (s). Our cardiologist states chest is clear to auscultation. Cardiovascular examination is normal. What would this constitute for the exam portion when counting the organ systems and the bullets? This is an established return visit for a patient that has a history of A-fib.

Thank you for your help.
 
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