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Physical Exam - What is the Extent of Physical Exam here

  1. #1
    Default Physical Exam - What is the Extent of Physical Exam here
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    What is the Extent of Physical Exam here:

    Vitals:
    Height: 6'0”
    Weight: 160

    Physical Examination: Patient is alert, appropriate, and comfortable. Patient holds a normal gaze. Pupils are round and reactive. Gait is normal. Skin is intact. No rashes, abrasions, contusions, or lacerations. No venous stasis. No pulses. No varicosities. No dyspnea. Reflexes are normal patellar. No clonus.

    Knee: Range of motion is apprximatly from 5 to 100 degrees. Pain with motion. No localized pain. Negative mechanical findings. There is effusion. Patella is tracking well. No tenderness. Patient feels pain especially when taking stairs or squatting.

    Hip: Exam is unremarkable. Normal range of motion, flexion approximately 105 degrees, extension approximately 10 degrees, abduction approximately 25 degrees, adduction approximately 30 degrees, internal rotation approximately 30 degrees, external rotation approximately 30 degrees.

    Neck: Neck is supple. No JVD.

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Detailed
    Detailed per 1995 guidelines.

    F Tessa Bartels, CPC, CEMC

  3. Default
    I see an 8 system general multi system exam (comprehensive) as per 1995 guidelines.

    Constitutional, psychiatry, eyes, musculoskeletal, integumentary, cardiovascular, nervous, neck.
    Thanks,
    Jagadish, CCS-P, CPC

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Neck is NOT an organ system
    Per the 1995 guidelines for a comprehensive exam you need to document 8 of the following 12 systems:
    Constitutional
    Eyes
    Ears, Nose, Mouth, Throat
    Cardiovascular
    Respiratory
    Gastrointestinal
    Genitoruinary
    Musculoskeletal
    Skin
    Neurologic
    Psychiatric
    Hematologic/Lymphatic/Immunological

    "Neck" is NOT one of the organ systems.

    By the way ... just looking at this documentation I shake my head "no pulses" Really? No pulse at all?

    F Tessa Bartels, CPC, CEMC

  5. #5
    Location
    North Carolina
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    3,126
    Default
    Tessa,

    You crack me up...

  6. #6
    Location
    Milwaukee WI
    Posts
    4,466
    Default Well ... it's Friday afternoon
    Quote Originally Posted by rebeccawoodward View Post
    Tessa,

    You crack me up...
    Well, Rebecca ... it's Friday afternoon... isn't it great to end the week with a laugh? Have a good weekend!
    Tessa

  7. Default
    If not neck, no dyspnea can be taken as exam element from respiratory system which makes this as comprehensive exam under 1995 DGs.
    Thanks,
    Jagadish, CCS-P, CPC

  8. #8
    Location
    North Carolina
    Posts
    3,126
    Default
    I can't say I agree with your view...

    Dyspnea by definition=difficult or labored respiration. This can be visually ascertained by the physician.

    I would not apply this exam statement to neck. This would follow under Respiratory (97 DG)... "assessment of respiratory effort" thus able to use this statement under respiratory for the 95's; or at least, I would.

  9. Default
    pls review my post again, i counted it under respiratory only.
    Quote Originally Posted by rebeccawoodward View Post
    I can't say I agree with your view...

    Dyspnea by definition=difficult or labored respiration. This can be visually ascertained by the physician.

    I would not apply this exam statement to neck. This would follow under Respiratory (97 DG)... "assessment of respiratory effort" thus able to use this statement under respiratory for the 95's; or at least, I would.
    Thanks,
    Jagadish, CCS-P, CPC

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