# Physical Exam



## krssy70 (Nov 24, 2009)

Patient declines the physical exam. The physican dictates very clearly that the patient does not want to have the physical Exam done today.  Does not state why....However, the physician did document the vitals, and noted that the patient is obese, and walks with a cane.  How would I count this Exam??


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## LLovett (Nov 24, 2009)

What type of visit is this? 

I am having a hard time picturing a sick person coming in to be seen and refusing an entire exam.

Laura, CPC, CEMC


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## krssy70 (Nov 24, 2009)

I agree. This is for an *post op office visit*. No global period. The following is exactly how the physician dictated the note.

Patient presents as an obese female, in no acute distress. She has a weight of greater than 350 pds, blood pressure is 132/91, with a pulse of 86 beats/minute and temp is 97.6 degrees Fahrenheit. Abdomen is obese. The patient is walking with a cane. She declines a physical exam today.

My question is when a patient declines an exam, Can you count that as a full exam because the physician CANT do the exam, not just that he didn't do it because he didn't have time, or didn't feel like, or even didnt dictate it completely. 

I hope that explains it better. Sorry


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## RGALVEZ (Nov 24, 2009)

Post op for what procedure? This may explain why the pt did not feel that the Dr needed to "exam" any other part of her.


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## LLovett (Nov 24, 2009)

You can't count it as complete. What you do have is problem focused.

Laura, CPC, CEMC


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## krssy70 (Nov 24, 2009)

The patient had a D & C Hysteroscopy. 

Thank you for the responses


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