Forum - Questions & Answers
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.