Physical Exam

Do you count Neurologic in the physical exam when the doctor documents that the patient is alert?

re: Physical Exam

Eyes of the beholder:
Psych: Alert and oriented to person, place and time;
Neuro: patient alert, relaxed and cooperative;
General (constitutional): The patient is alert, in no acute distress.

re: Physical Exam

OK, so what if you already have constitutional with vital signs, but the documentation has "General (constitutional): The patient is alert, in no acute distress."

re: Physical Exam

The neurologic part states cranial nerves, deep tendon reflexes, sensations. But Psych states judgement, orientation, mood and affect. It would fit best under Psych.