Morning,
This is going to be a long one but I am just trying to get a handle on the exam element of an audit. We follow 1995 guidelines.
The note that follows is from a vist with a podiatrist.
Vital Signs
Patient Profile: XX year old male
Height: XX inches
Weight: XXX lbs
Prior Weight: XXX lbs
BMI: XXX
Pulse rate: XX beats per minute
Pulse rhythm: regular
Resp: XX per minute
BP sitting: XXX/XX (left arm sitting)
Cuff: regular
I would give the vitals one bullet in the constitution (general) area for the exam.
Foot/Ankle Exam
General:
Well-developed, well-nourished, in no acute distress; alert and oriented x3.
one bullet for the constitution(general) area of the exam
Gait:
Noral heel-toe gait pattern bilaterally.
one bullet musculoskeletal area
Skin:
Cellulitis of b/l lower legs and feet is markedly improved from a week ago. Most of the bulla between his toes have ruptured other than between the right hallux and second toe. Still some serous drainage from the toes as well as interdigital maceration numerous bull to b/l lower leg. No purulence noted. one bullet for skin
Inspection:
No gross malalignment. one bullet for musculoskeletal area
Palpation:
Still tender to palpation and manipulation of the toes. one bullet for musculoskeletal area
Vascular:
Dosalis pedis and posterior tibial pulses 2+ and symmeytric, capillary refill <2 seconds, normal hair pattern, no evidence of ischemia. 2 bullets for cardiovascular area
Sensory:
Gross sensation intact bilaterally in lower extremities
Motor:
Normal b/l
Reflexes:
Normal and Symmetric 2 bullets for neurologic area
We follow 1995 guidelines. I count 10 bullets. This would be an expanded problem focused exam. Any help would be greatly appreciated. Thank You.
This is going to be a long one but I am just trying to get a handle on the exam element of an audit. We follow 1995 guidelines.
The note that follows is from a vist with a podiatrist.
Vital Signs
Patient Profile: XX year old male
Height: XX inches
Weight: XXX lbs
Prior Weight: XXX lbs
BMI: XXX
Pulse rate: XX beats per minute
Pulse rhythm: regular
Resp: XX per minute
BP sitting: XXX/XX (left arm sitting)
Cuff: regular
I would give the vitals one bullet in the constitution (general) area for the exam.
Foot/Ankle Exam
General:
Well-developed, well-nourished, in no acute distress; alert and oriented x3.
one bullet for the constitution(general) area of the exam
Gait:
Noral heel-toe gait pattern bilaterally.
one bullet musculoskeletal area
Skin:
Cellulitis of b/l lower legs and feet is markedly improved from a week ago. Most of the bulla between his toes have ruptured other than between the right hallux and second toe. Still some serous drainage from the toes as well as interdigital maceration numerous bull to b/l lower leg. No purulence noted. one bullet for skin
Inspection:
No gross malalignment. one bullet for musculoskeletal area
Palpation:
Still tender to palpation and manipulation of the toes. one bullet for musculoskeletal area
Vascular:
Dosalis pedis and posterior tibial pulses 2+ and symmeytric, capillary refill <2 seconds, normal hair pattern, no evidence of ischemia. 2 bullets for cardiovascular area
Sensory:
Gross sensation intact bilaterally in lower extremities
Motor:
Normal b/l
Reflexes:
Normal and Symmetric 2 bullets for neurologic area
We follow 1995 guidelines. I count 10 bullets. This would be an expanded problem focused exam. Any help would be greatly appreciated. Thank You.
