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Posted By Mary Peabody on 04-28-2020, 15:29:18 in Ob-Gyn
Hello Melanie,

Would you agree that only four organ systems are examined based on this not : Constitutional, Eyes, Resp, Psy ? Would you give credit for neuro for "alert"? Head is a body area. Some coders are counting this as an organ system

Physical Exam
Constitutional:
General: She is awake. She is not in acute distress.
Appearance: She is well-developed and well-groomed. She is not ill-appearing or toxic-appearing.
HENT:
Head: Normocephalic and atraumatic.
Eyes:
Extraocular Movements: Extraocular movements intact.
Pulmonary:
Effort: Pulmonary effort is normal. No respiratory distress.
Comments:
Able to speak in full sentences without pause
No cough noted
Neurological:
Mental Status: She is alert.
Psychiatric:
Attention and Perception: Attention normal.
Mood and Affect: Affect normal. Mood is anxious.
Comments (1)
Posted By Melanie Witt on 04-30-2020, 16:16:07
First, listing her mental status as alert is NOT part of an examination of the neurological organ system. The elements for that exam would include such things as testing cranial nerves, doing deep tendon reflexing tests (like on the knees), or checking for the presence or absences of sensation or testing for coordination. An examination of of psychiatric system would include mood and affect, orientation and mental status. So in this exam you have listed above you have 4 organ systems (constitutional, eyes, pulmonary and psychiatric and 1 body area (head). I would not count anything for the ENT (which would be ears, nose and throat) as they are not documented as having been looked at, only the head (which is also supposed to include the face). You should also know that there is no exam element in the 1997 guidelines that covers "head" except in relation to the ENT specialty examination.

Examination of deep tendon reflexes with notation of pathological reflexes (e.g., Babinski)

Examination of sensation
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