Search results
Jul 12, 2022 · More than one qualified practitioner can participate in performing, documenting, and authenticating an H&P for a single patient. When more than one practitioner participates in completing the H & P, each entry must be signed, dated and timed by the author of that entry.
- Key Information
- Pelvic Examination
- Visual Examination
- Visual Field Examination
Masses and enlarged organs (organomegaly; hepatomegaly; splenomegaly); palpable lymph nodes; jaundice (yellowing of skin and eyes due to blockage of bileducts).
Manual or speculum evaluation of cervix, vagina, rectum, externalgenitalia. Digital examination of the rectum and vagina is also called a rectovaginal exam.
Visualization of clinically accessible areas of the head and neckby viewing them in a mirror or through an endoscope (see also Endoscopies).
A test to determine any defects in the patient's vision, which in turn may reveal the location of a brain tumor. Visual field alterations caused by problems in different brainsites are unique.
For each diagnosis discuss physiologic disease basis relevant to the patient and elements from the patient’s history and physical that either support or refute the diagnosis. For each item on your differential, explain what makes it likely AND what makes it less likely.
- 265KB
- 7
May 14, 2013 · For accuracy of coding, list all current diagnoses. If a diagnosis is listed but is no longer present or no longer being treated, document that it was resolved prior to admission. Include documentation of the etiology, severity and acuity of the diagnosis (es), if known.
For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.
- 172KB
- 16
Jul 12, 2016 · The scope of the physiatric H&P varies enormously depending on the setting, from the focused assessment of an isolated knee injury in an outpatient setting, to the comprehensive evaluation of a patient with traumatic brain or spinal cord injury admitted for inpatient rehabilitation.
People also ask
Should a physician perform a physical exam after a history?
How is a physical exam documented?
What is the history portion of a medical record?
Who must complete a H & P?
General Documentation Principles. The medical record should be complete and legible Documentation of each patient encounter should include: Reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.
