AdamlShoop
Networker
While learning E/M. The reports i'm practicing show a doctor doing exams that involve certain checks. The paperwork i'm learning from shows me items such as "cardiovascular" and then lists a few bulleted items with some examples.
Are these examples the ONLY things allowed to be mentioned in the report to earn a point? I am seeing doctors talk about certain things, and the term does not show up in my example, so I am reluctant to assign a point unless I see that term, or a meaning that describes that term.
Such as "extraocular nerves in tact" and "extraocular movements in tact" I am assuming those are the same thing, although i've been taught not to assume, and that if it isn't documented right, don't assign a point to it. I hope this makes sense, because it is really slowing me down, and i'm finding that i am getting alot of these wrong.
I also understand that i will get alot wrong at first, I just want to know WHY i am getting them wrong, so that i can get a deeper understanding of these things soon... Thank you.
Are these examples the ONLY things allowed to be mentioned in the report to earn a point? I am seeing doctors talk about certain things, and the term does not show up in my example, so I am reluctant to assign a point unless I see that term, or a meaning that describes that term.
Such as "extraocular nerves in tact" and "extraocular movements in tact" I am assuming those are the same thing, although i've been taught not to assume, and that if it isn't documented right, don't assign a point to it. I hope this makes sense, because it is really slowing me down, and i'm finding that i am getting alot of these wrong.
I also understand that i will get alot wrong at first, I just want to know WHY i am getting them wrong, so that i can get a deeper understanding of these things soon... Thank you.