AmandaW
Guru
PLEASE provide any clarification that you can on this.
Under exam, 1995 guidelines, for a comprehensive (8) I understand you must do organ systems, correct?
If they say abdomen, can I convert that to GI? I know definitley no 'double dipping' as far as counting abdomen and GI twice for two, can only count as one, but if it's documented as a body area, can I convert that to the organ system? Chest - (whether they talk about pulmonary or heart) would be either respiratory or cardiovascular, abdomen - GI....Head - musculoskeletal, etc. (??)
For example:
Constitutional: General Appearance: healthy-appearing, well-nourished, and well-developed. Ambulation: ambulating normally.
Psychiatric: Insight: good judgement. Mental Status: active and alert and normal mood. Orientation: to time, place, and person. Memory: recent memory normal and remote memory normal.
Head: Head: normocephalic.
Eyes: Pupils: PERRLA. Lens: clear.
ENMT: Ears: no lesions on external ear.
Neck: Neck: supple and trachea midline.
Lungs: Respiratory effort: no dyspnea.
Cardiovascular: Neck vessels: no JVD.
Abdomen: Bowel Sounds: normal. Inspection and Palpation: no tenderness, guarding, masses, rebound tenderness, or CVA tenderness and soft and non-distended. Liver: non-tender. Spleen: non-tender. Hernia: none palpable.
Musculoskeletal:: Extremities: no cyanosis or edema.
Neurologic: Gait and Station: normal gait.
Skin: Inspection and palpation: no lesions or jaundice. Nails: normal.
Under exam, 1995 guidelines, for a comprehensive (8) I understand you must do organ systems, correct?
If they say abdomen, can I convert that to GI? I know definitley no 'double dipping' as far as counting abdomen and GI twice for two, can only count as one, but if it's documented as a body area, can I convert that to the organ system? Chest - (whether they talk about pulmonary or heart) would be either respiratory or cardiovascular, abdomen - GI....Head - musculoskeletal, etc. (??)
For example:
Constitutional: General Appearance: healthy-appearing, well-nourished, and well-developed. Ambulation: ambulating normally.
Psychiatric: Insight: good judgement. Mental Status: active and alert and normal mood. Orientation: to time, place, and person. Memory: recent memory normal and remote memory normal.
Head: Head: normocephalic.
Eyes: Pupils: PERRLA. Lens: clear.
ENMT: Ears: no lesions on external ear.
Neck: Neck: supple and trachea midline.
Lungs: Respiratory effort: no dyspnea.
Cardiovascular: Neck vessels: no JVD.
Abdomen: Bowel Sounds: normal. Inspection and Palpation: no tenderness, guarding, masses, rebound tenderness, or CVA tenderness and soft and non-distended. Liver: non-tender. Spleen: non-tender. Hernia: none palpable.
Musculoskeletal:: Extremities: no cyanosis or edema.
Neurologic: Gait and Station: normal gait.
Skin: Inspection and palpation: no lesions or jaundice. Nails: normal.
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