Physical Exam...

Hello all...

I have a doctor that's does very minimal exams- and I just need to verify with others that I am doing this correctly...

Here is his exam exactly as put in the new patient consult notes....

On exam today she looks pretty good for her age. She is 62 inches and 154 pounds with normal vital signs. The right breast has healed nicely. Scars are not tender. She has no lumps in either breast. No skin lesions. No adenopathy. No skin lesions of any concern other than the lot of keratoses. She is intact neurologically and the rest of her exams are unremarkable.

I gave him 2 bullets.....1-skin, 1-neuro giving him an EPF exam. Correct?

Also, we can not count this is as a complete exam due to "and the rest of her exams are unremarkable."

Thanks for your help : )

exam

what about the Lymphatic system and Constitutional system?
"Unremarkable" does not count for a complete. Many payors are now requiring listing the systems examined.
The 1995 guidelines list breasts as a body part

Physical Exam...

I thought that we weren't allowed to count the constitutional because you need to list 3 vitals, he does 2? Also, I have to have 2 lymphs noted to be counted as one, I thought....

I have a templete that goes by the 95 guidelines- I'm not sure about other places but here, we are lucky to get 1995 guidelines in our notes...hahaha!!!

1995 guidelines

It sounds like you are mixing the 1997 with the 1995, you should follow one or the other

1997 guidelines only include

1997: Constitutional Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
1997 - Lymphatic Palpation of lymph nodes in two or more areas:
Neck
Axillae
Groin
Other

1995 physical exam

For purposes of examination, the following body areas are recognized:
• Head, including the face
• Neck
• Chest, including breasts and axillae
• Abdomen
• Genitalia, groin, buttocks
• Back, including spine
• Each extremity
For purposes of examination, the following organ systems are recognized:
• Constitutional (e.g., vital signs, general appearance)
• Eyes
• Ears, nose, mouth and throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric
• Hematologic/lymphatic/immunologic

1995 physical exam

For this note, I count:

constitutional (as Nancy points out, for the 1995 Guidelines, you don't need three vitals, as you do for the 1997)

Breast

Lymph

Skin

Maybe neuro.

But, I would call it a "limited exam of 2-7 systems" and would not count it as a detailed exam.

There's a long article in the database. Type 1995 Exam in the search box, and it comes up. You could also browse entries by tag, and see all articles related to the Documentation Guidelines and Auditing.

Physical Exam...

Thank you so much for all your help! I still can't even say enough about this website!!!