btadlock1
Guest
That is the question...
I've got some new ones to get everyone's thoughts on...Some I know, but some I'm not sure about, so I'll just copy all of them...I'm only interested in where you'd credit on 1997 guidelines, please - (I can't score it on 1995 due to our protocol.)
CC: Cough, SOB (COPD)
General: Awake. Alert. Appropriate.
Head: No sign of injury (<---I thought this one was odd)
Ears: No TM erythema, No edema. Landmarks clear.
Oropharynx: No erythema. No exudate.
Neck: Supple. No adenopathy, full ROM
Respiratory: Lungs CTA, respirations non-labored, breath sounds are equal. Symmetrical chest wall expansion. No chest wall tenderness
Cardiovascular: Regular rate and rhythm
GI: Soft. Bowel sounds active. Non-distended. Non-tender. No guarding, rigidity, distention or tenderness. (A little redundant...)
Neurological: CN II-XII intact
Integumentary: Warm Dry Pink & Intact
Psychological: AOx4
I've got bullets for:
2 Constitutional (vitals are also documented)
2 ENT: (otoscopic exam of TM, exam of oropharynx)
1 Neck: exam of neck
2 Resp: Ascultation of lungs, assessment of resp. effort
1 CV: ascultation of heart
2 GI: exam of abdomen, exam of liver/spleen (I count for 'no distention')
2 Musculoskeletal (neck, spine/ribs/pelvis): inspection and/or palpation w/notation of tenderness
1 neuro: Test Cranial nerves
1 psych: orientation to time, place, person
The things I'm unsure of are:
"Appropriate" - enough to count for psych, mood and affect?
"Landmarks clear" - I've never seen that before...
"No sign of injury" - that just seems so random...does it count for anything?
Are there any others that I might have missed? I'd like to make the provider's education as accurate as possible, so I want to give credit everywhere it's due...please let me know what you think!
I've got some new ones to get everyone's thoughts on...Some I know, but some I'm not sure about, so I'll just copy all of them...I'm only interested in where you'd credit on 1997 guidelines, please - (I can't score it on 1995 due to our protocol.)
CC: Cough, SOB (COPD)
General: Awake. Alert. Appropriate.
Head: No sign of injury (<---I thought this one was odd)
Ears: No TM erythema, No edema. Landmarks clear.
Oropharynx: No erythema. No exudate.
Neck: Supple. No adenopathy, full ROM
Respiratory: Lungs CTA, respirations non-labored, breath sounds are equal. Symmetrical chest wall expansion. No chest wall tenderness
Cardiovascular: Regular rate and rhythm
GI: Soft. Bowel sounds active. Non-distended. Non-tender. No guarding, rigidity, distention or tenderness. (A little redundant...)
Neurological: CN II-XII intact
Integumentary: Warm Dry Pink & Intact
Psychological: AOx4
I've got bullets for:
2 Constitutional (vitals are also documented)
2 ENT: (otoscopic exam of TM, exam of oropharynx)
1 Neck: exam of neck
2 Resp: Ascultation of lungs, assessment of resp. effort
1 CV: ascultation of heart
2 GI: exam of abdomen, exam of liver/spleen (I count for 'no distention')
2 Musculoskeletal (neck, spine/ribs/pelvis): inspection and/or palpation w/notation of tenderness
1 neuro: Test Cranial nerves
1 psych: orientation to time, place, person
The things I'm unsure of are:
"Appropriate" - enough to count for psych, mood and affect?
"Landmarks clear" - I've never seen that before...
"No sign of injury" - that just seems so random...does it count for anything?
Are there any others that I might have missed? I'd like to make the provider's education as accurate as possible, so I want to give credit everywhere it's due...please let me know what you think!