If a physician puts "benign" on abdominal examination, is this acceptable? Would this be the same as stating "WNL"?
Vital Signs: Temp 98.3, HR 79 RR 17 BP 131/58 Sat 97%
General: She is disorganized perseverating about adopting a child in China. She is uncooperative to the physical exam.
CV: Normal rate, rhythm
Lower extremities: with cigarette burn on the left side of the LLL. no edema.
Neurologic: Exam seems to be nonfocal.
I get 7 elements with none in detail if you count abdomen as WNL. Can someone else double check this?
Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.
1 post • Page 1 of 1