Wiki 1995 Physical Exam Body areas and systems

[Svirgilio]

Can both body areas and systems be included together. I noticed on some of our providers physical exams they have both body areas and systems. See the example below. See how the extremities which are considered a body area be listed alongside systems such as skin. Can extremities be counted as musculoskeletal and can the neck exam be counted under lymphatic? Using the 1995 guidelines does this satisfy a detailed exam or comprehensive exam?

Physical Exam:
Vitals: Blood pressure 133/50, heart rate 83, respirations 20. Patient is afebrile.
General: The patient is sitting up at the edge of her bed. Appears in no acute distress. The patient does appear generally debilitated.
HEENT: Sclerae anicteric, conjunctivae uninflamed. Pupils are reactive to light and accommodation. Mucous membranes are moist.
Neck: Supple, with no lymphadenopathy.
Heart: Regular rate and rhythm, no murmur, no JVD. Peripheral pulses are palpable.
Lungs: Clear to auscultation, with breath sounds equal bilaterally.
Abdomen: Soft, nontender, and nondistended, no guarding or rebound. Normal bowel sounds. No masses.
EXT: No edema, no clubbing. Peripheral pulses palpable. Joints are normal.
Neuro: No tremor. The patient is awake, alert, and oriented x3. Baseline mentation.
Skin: Good turgor, no rash.

 

[dclark7]

Yes, but you must use one or the other, not both. For neck, you could count this as a body area or you could count it as a system (lymph). The same with extremities. You could count it as extremities or with this exam you get two systems, cardiovascular (no edema, pulses palpable) and musculoskeletal (joints normal),but you already have C/V under heart.

You cannot mix body areas and organ systems for the comprehensive level exam, you can only use organ systems. With this exam you have Constitutional, Eyes, Lymph, C/V, Resp, GI, M/S, Neuro, Integ,; which is nine organ systems. So this would qualify as comprehensive under 95 guidelines.

 

[Svirgilio]

Thank you. I appreciate you taking the time to answer my post. This helps me to understand that you can only count one or the other but not both.