Wiki Exam -- constitutional

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msingh23

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The following has been document into patient chart for a orthopedic visit, would this qualify for points towards constitutional in the Exam when there was nothing indicate under the exam portion of the chart notes. Appreciate feedback on both as new pt and est. pt.
Vital Signs
Height: 67 inches
Weight: 196 pounds
Thanks
 
I would say no, this would not count as constitutional. For it to count, for either new or established there has to be at least three of the seven options.
 
Depends on the guidelines being used

There are no specified requirements defined in 95 for what has to be documented under the system to get credit for it. So if this was all the documentation you had for a new or established patient, under 95 this would support a problem focused exam.

I do agree that this would not count under 97 since you are required to have 3 or more vitals for that bullet or a statement regarding general appearance for the other possible constitutional bullet.

Laura, CPC, CPMA, CPC-I, CEMC
 
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