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drhoads

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While performing a recent chart audit the physician states " head is normocephalic atraumatic". Could I give him credit in the exam section under organ systerms for ears, nose, mouth and throat? According to the definition "normocehpalic" which means all major organs in the head are normal leads me to believe I could count this in the exam section. Thank you
 
I would ask the doctor what he means normocephalic and atraumatic. If your doctors standard of care includes a throat exam in the normocephalic description then yes. however if it does not then no. Usually normocephalic does not include a throat examination, but every doctor is different and documents differently. However it can include the external surface of a head which would include the visual components that would be visible to a physician upon looking at the patient head and face.
 
Musculoskeletal

When our pediatric surgeons stated "normocephalic/atraumatic" they are referring to the shape of the baby's skull and facial bones. So we count this as musculoskeletal.

BUT ...

I know this because we have had a conversation about this terminology, have agreed to use it in this specific manner consistently within the practice, and have this recorded in our protocols.


Hope that helps.

F Tessa Bartels, CPC, CEMC
 
I'm sorry, i have just one more question. If it was determined as to whether or not the physician passed or failed his audit, would you give him credit in the exam section for the statement "normocephalic/atraumatic" in the musculoskeletal section?
 
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