Physicians who have been examining patients for a while and documenting those visits tend to have their own internal checklist for their findings. They will use the same phrases over and over, especially when there is no "abnormal" finding. And they will document the exam in the same order (vitals, Eyes, ENT, resp, CV, GI, GU, MS (extremities), skin, neuro, psych).
That's not cut-and-paste, nor is it in any way indicative of their not having performed what they document they have performed. It is perfectly fine.
I used to transcribe for physicians with patients in the ICU. Very sick patients. And I recognized patterns in the way each physician recorded certain information. Doesn't mean they didn't perform the exam, it was just the way they phrased their documentation. Today, if I read just the exam portion of a note from the ICU, I could probably still identify which doctor was seeing the patient, just by recognizing certain phrasing.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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