Wiki how would you score this?

[bedforak1]

Would you give the provider a EPF or Detailed exam for this?

Vital Signs and Measurements:
Temp 97.5
Peripheral Pulse 72 BPM
Systolic BP 197 mmHG
Diastolic BP 80mmHG
Resp Rate 16RR
O2 Sat 89%

Lab Results
Blood Glucose 213 mg/dL

 

[a.montaruli@gmail.com]

This to me is actually only a Problem Focused Exam. I am only seeing one organ system (constitutional) being represented here. You have 5 of the 7 vital signs however the status of them is not mentioned. This would not be considered a detailed exam. Vital signs are or should be routine on almost every encounter.

Hope this helps,
Andrew

 

[amottice]

problem focused

 

[MnTwins29]

I too agree with PF - vital signs do not qualify in any of the organ systems, i.e. BP values cannot be used for cardiovascular.