HCCCoder
Guru
Hello all,
I used to always go by 1997 guidelines. I changed my job and now they require us to use 1995 for general multi-system.
I have this medical record, where I want to make sure I get the correct level of the physical exam.
It is written:
Area Normal
GENERAL
SKIN
HEENT
NECK
BREAST
CHEST
HEART
ABDOMEN
EXTREMITIES
GU/PELVIC
NEURO
There are 2 columns one says "Area" and other one "Normal" and doctor draw a line from top to the bottom, indicating that every system examined was normal.
First of all, is it OK when doctor just draws a line from top to the bottom under column "normal"?
And second, do you get comprehensive PE, according to 1995 guidelines?
Do you get 8 bullets?
Thank you in advance,
Lilit
I used to always go by 1997 guidelines. I changed my job and now they require us to use 1995 for general multi-system.
I have this medical record, where I want to make sure I get the correct level of the physical exam.
It is written:
Area Normal
GENERAL
SKIN
HEENT
NECK
BREAST
CHEST
HEART
ABDOMEN
EXTREMITIES
GU/PELVIC
NEURO
There are 2 columns one says "Area" and other one "Normal" and doctor draw a line from top to the bottom, indicating that every system examined was normal.
First of all, is it OK when doctor just draws a line from top to the bottom under column "normal"?
And second, do you get comprehensive PE, according to 1995 guidelines?
Do you get 8 bullets?
Thank you in advance,
Lilit
Last edited: