Wiki "no obvious paresis"

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chelbi

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While auditing hospitalists charts I'm faced with deciding where :confused: (if anywhere) to give credit for the statement of an unresponsive patient "no obvious paresis." Is this applicapable to musculo? Neuro? If musculo is it applicable to stability? strength and tone? ROM? credit for all extremities or just once since there is no indication all 4 were checked (is it 'understood' all four were?)??

Opinions?:D

Thanks for feedback!

Michelle Myrick, CPC, CPC-I
 
For that general statement, I would only give one bullet for neuro. The "no obvious" leads me to believe he's done a casual quick-look and not a hands-on exam. I sure would not give him any MS bullets for this statement without some additional documentation of what he did and what he found
 
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