imaginethat23
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Good morning!
I'm trying to get some feedback on how several of my providers document findings in their Exams. Being somewhat new to this, I'm questioning whether clarification is needed or if the documentation would suffice.
Specifically, I'm questioning the GI system notes and feel that the providers are interchanging "GI" with "Abdomen". This is an example of what I see:
Gastrointestinal: soft, non-tender
I've searched a lot of resources and I've seen "Abdomen: soft, non-tender" and "Gastrointestinal: Abdomen is soft, non-tender" but nothing that matches what I'm seeing. Personally, I feel they should be specifying Abdomen when notating that information under the GI system, but maybe I'm being too picky?
Any thoughts/opinions would be greatly appreciated!
I'm trying to get some feedback on how several of my providers document findings in their Exams. Being somewhat new to this, I'm questioning whether clarification is needed or if the documentation would suffice.
Specifically, I'm questioning the GI system notes and feel that the providers are interchanging "GI" with "Abdomen". This is an example of what I see:
Gastrointestinal: soft, non-tender
I've searched a lot of resources and I've seen "Abdomen: soft, non-tender" and "Gastrointestinal: Abdomen is soft, non-tender" but nothing that matches what I'm seeing. Personally, I feel they should be specifying Abdomen when notating that information under the GI system, but maybe I'm being too picky?
Any thoughts/opinions would be greatly appreciated!