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Neuro exam or extremities? sm - GT

Posted: Jun 22, 2015

When the doctor dictates about the gait and tandem gait, do you leave that under extremities if he dictates it there? He usually says it at very end of physical exam, and I am unsure if he just forgot to dictate "NEUROLOGICAL" heading or what. Sometimes he does dictate a NEUROLOGICAL heading and puts the gait there as well as other things, but then many times he dictates it at end of extremities and does not give separate heading. What would be the appropriate thing to do in this case?

Check your acct guidelines - but

[ In Reply To ..]
I would leave as dictated unless the account guidelines specify to change it.

Personally, I add NEUROLOGIC: - NJMT

[ In Reply To ..]
Since not really part of extremity exam but the neurologic exam. I work for a company STRICTLY follows the BOS, and I add headings for such things all the time and don't get dinged. If all else fails, ask.

definitely need to ask your company - and do as they direct

[ In Reply To ..]
It can be part of either the extremity exam or part of the neurological exam; neither is wrong, but it is a matter of what the person who pays you wants.

I do a lot of orthopedics and that term is stated commonly on the extremity exam. I never add a heading for it. I type as dictated.

(I'm scratching my head wondering what the BOS has to do with someone deciding to add a heading and never getting dinged for it...)

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