Post
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.
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.
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