kviolet
Networker
Below is a copy of Dr X pt’s exam:
I found 7 organ systems.
am I correct ?
Physical Exam:
· Gen: Alert WDWN NAD No Pallor Moist Mucosa (1)
· Head: NCAT (body area)
· Eyes: Conj/lids within normal limits (2)
· Neck: No Meningismus No Adenopathy (body area)
· Lungs: CTA No wheezes/rhonchi/rales No retractions (3)
· CV: Normal Perfusion Peripheral Pulses Normal RRR No murmurs/gallops/rubs (4)
· GI: Soft Non-tender – point to body areas “abdomen” not Organ system “GI” because in order to get GI credit it should have more documentation for example mention about HSM or hernias
· Skin: right great toe - base of 1st MTP with blister that then leads into a dark discolored toe, nail is everted at its tip, + erythema proximal to the MTP joint. no tenderness. (5)
normal gait (6) neuro no fluctuance. no induration.
· Extrem: FROM Capillary refill within normal limits Peripheral pulses within normal limits (7)
Belowis a respond from the ED doctor :
Thanks - but this really can’t be accurate- this is an interpretation/understanding problem:
Head and Neck should be considered an organ system just the same as “GEN: WDWN NAD No Pallor Moist Mucosa”
HEAD: includes organ systems neuro and musculoskeletal (bones): so NCAT (Normocephalic, Atraumatic)- means that the skull bones were intact, head size was normal ( for example no microcephaly or macrocephaly which might indicate a neurological condition)
Neck- includes organ systems such as NEURO and LYMPHATIC: so that
“Neck: No Meningismus No Adenopathy”- MUST be interpreted- with that in mind- “no meningismus” means that there were no neurological signs of infection and “no adenopathy” means that there were no local signs of lymphatic infection of the throat, ears, etc).
Please clarify again why things like Head and Neck should be excluded.
Also for GI- when the doctor’s write “soft, non-tender”- it is UNDERSTOOD that refers to abdomen. It should be entirely sufficient to write abdomen-soft, non-tender ( for getting credit for 1 body part in 1 organ system).
Unless you are saying that you need more than 1 element per organ system.
thanks
How should I reply ? Thanks for any help!!!
I found 7 organ systems.
am I correct ?
Physical Exam:
· Gen: Alert WDWN NAD No Pallor Moist Mucosa (1)
· Head: NCAT (body area)
· Eyes: Conj/lids within normal limits (2)
· Neck: No Meningismus No Adenopathy (body area)
· Lungs: CTA No wheezes/rhonchi/rales No retractions (3)
· CV: Normal Perfusion Peripheral Pulses Normal RRR No murmurs/gallops/rubs (4)
· GI: Soft Non-tender – point to body areas “abdomen” not Organ system “GI” because in order to get GI credit it should have more documentation for example mention about HSM or hernias
· Skin: right great toe - base of 1st MTP with blister that then leads into a dark discolored toe, nail is everted at its tip, + erythema proximal to the MTP joint. no tenderness. (5)
normal gait (6) neuro no fluctuance. no induration.
· Extrem: FROM Capillary refill within normal limits Peripheral pulses within normal limits (7)
Belowis a respond from the ED doctor :
Thanks - but this really can’t be accurate- this is an interpretation/understanding problem:
Head and Neck should be considered an organ system just the same as “GEN: WDWN NAD No Pallor Moist Mucosa”
HEAD: includes organ systems neuro and musculoskeletal (bones): so NCAT (Normocephalic, Atraumatic)- means that the skull bones were intact, head size was normal ( for example no microcephaly or macrocephaly which might indicate a neurological condition)
Neck- includes organ systems such as NEURO and LYMPHATIC: so that
“Neck: No Meningismus No Adenopathy”- MUST be interpreted- with that in mind- “no meningismus” means that there were no neurological signs of infection and “no adenopathy” means that there were no local signs of lymphatic infection of the throat, ears, etc).
Please clarify again why things like Head and Neck should be excluded.
Also for GI- when the doctor’s write “soft, non-tender”- it is UNDERSTOOD that refers to abdomen. It should be entirely sufficient to write abdomen-soft, non-tender ( for getting credit for 1 body part in 1 organ system).
Unless you are saying that you need more than 1 element per organ system.
thanks
How should I reply ? Thanks for any help!!!