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Wiki Physical Exam?

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Coder708

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Our Dr. uses a Template for his PE... it has each system on it and certain bullets. problem is that he does not check off a bullet point on some of the systems he writes NO ABNORMAL FINDINGS...So does this count as a bullet??
IS this compliant ?? does anyone else use a template like this . Your feed back would be greatly appreciated.
 
A brief statement or notation indicating "negative" or "normail" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ systems.

We use 97 guidelines

God I wish I could remember which reference book this is from! Hope it helps!
 
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