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Physical Exam

  1. #1
    Default Physical Exam
    Exam Training Packages
    For a comprehensive Exam - for a multi system Exam
    I am utilizing the 1997 documentation guidelines:

    It states "should include at least nine organ systems or body areas. For each system/area selected, all elements of the exam identified by a bullet should be performed, unless specific directions limit the content of the exam. For each area/system, documenation of at least two elements identified by a bullet is expected.

    Can someone please explain: By the wording in the statment, it is a bit confusing. Does this mean that all the physician needs to document is nine systems/body areas, with all elements identified by a bullet, or:
    each system/body areas need 2 bullets each.

    please help,
    Kristen Richard, CPC

  2. #2
    Milwaukee WI
    Default Documentation of 1997 Comprehensive Exam
    The physician is supposed to perform all elements in at least 9 different areas/systems.

    The physician must document at least 2 bullets from each of nine different systems or body areas.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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