This exam does not meet detailed exam using 1995, 1997 and Musculoskeletal Specialty Audit tools. Would you consider using clinical inference to meet the detailed exam required for the level of service billed? Documentation below.
Documented height, weight and BMI.
Well appearing female.Appears stated age.
Normocephalic, atraumatic. Face is symmetrical with no issues.
Neck- supple
Musculoskeletal: spine is straight with no midline defects. No evidence of scoliosis. She is neurovascularly intact in the bilateral upper and lower extremities. Her hip extends to 0, flexes to 120, internally rotates to 60, externally rotates to 70. Very minimal tenderness with external rotation. Negative log roll. Negative heel strike. Has zero degree popliteal angles bilaterally. Very minimal pain with resisted leg extension and flexion. She can walk without a limp. Can hop without significan pain. Neurovascularly intact distally. No limp detected.
Documented height, weight and BMI.
Well appearing female.Appears stated age.
Normocephalic, atraumatic. Face is symmetrical with no issues.
Neck- supple
Musculoskeletal: spine is straight with no midline defects. No evidence of scoliosis. She is neurovascularly intact in the bilateral upper and lower extremities. Her hip extends to 0, flexes to 120, internally rotates to 60, externally rotates to 70. Very minimal tenderness with external rotation. Negative log roll. Negative heel strike. Has zero degree popliteal angles bilaterally. Very minimal pain with resisted leg extension and flexion. She can walk without a limp. Can hop without significan pain. Neurovascularly intact distally. No limp detected.