dgerry
Networker
I have a provider that has this statement in his new patient dictation:
O: Healthy-appearing female/male in no acute distress. Head: Normocephalic/atraumatic. Neck: Supple. Lungs: No shortness of breath, no audible wheezes. Heart: Regular rate and rhythm. Abdomen: Benign.
He then dictates his musculoskeletal exam for the body area(s) the patient is being seen for and any related areas. My question is, in an audit would the statement above be a problem? Orthopaedic surgeon.
I really appreciate any opinions and assistance!
O: Healthy-appearing female/male in no acute distress. Head: Normocephalic/atraumatic. Neck: Supple. Lungs: No shortness of breath, no audible wheezes. Heart: Regular rate and rhythm. Abdomen: Benign.
He then dictates his musculoskeletal exam for the body area(s) the patient is being seen for and any related areas. My question is, in an audit would the statement above be a problem? Orthopaedic surgeon.
I really appreciate any opinions and assistance!