Psychiatric Examination

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.

Moderators: Shannon DeConda, NAMAS Moderator

Psychiatric Examination

Postby Shoshana » Thu Oct 18, 2018 5:41 pm

Does this meet complete for 1997 Psychiatric exam? I think no.
Physical findings - BP 142/77, Pulse - 77 bpm, Height 61 in., weight 132 lbs. BMI 25.1 and Body Surface Area 1.59 m2
Mental status exam:
Patient is well developed and well-nourished and appears stated chronological age. Patient appears to be in no acute physical distress.
Appearance: Neatly dressed and groomed
Attitude: Cooperative, amicable
Speech: rate/volume wnl, good articulation, vocabulary consistent with age/level of education
Motor: No abnormal movements
Cognition: wnl
Attention/Concentration: Fair to good one-to-one interaction
Recent/Remote Memory: Good
Mood: "anxious"
Affect: Anxious
Thought Process: Distractable
Thought Content: No hallucinations or delusions present. No obsessions present.
Insight: Fair
Judgment: Good

I only get "detailed" on the 1997 examination.

Missing: Discription of associations (eg, loose, tangential, circumstantial, intact), and Language
Under speech I gave credit for description of speech (rate/volume wnl; good articulation) and Fund of knowledge (vocabulary consistent with age/level of education)

I just want verification I am not missing something since I rarely see the 97 examination used except in psychiatry.
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
Shoshana
 
Posts: 73
Joined: Fri Jun 23, 2017 5:41 pm
Location: Multi-specialty Clinic

Return to Medical Auditing Forum

Who is online

Users browsing this forum: No registered users and 3 guests

cron