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Physical exam headings... - sw

Posted: Apr 19, 2010

I really have a problem under the Physical Examination trying to figure out what goes where when the headings aren't dictated. For instance, in this dictation, she dictates lungs, describes her exam of them, then goes on to say, "Mass in the back and the left paraspinous area is measured..." Would this stay under the lungs or would I make a new heading...if so, if "Back" an acceptable heading?

Next, she talks about the pelvis...would this go under a heading with a "Pelvis" label? Also, perhaps this is client-based (which I can't find out b/c this is for an application), but when discussing the heart, which label is more appropriate? Heart or cardiac? I had both in the course I took, and I'm not sure if they are necessarily interchangeable or not.

Thanks so much!

Depends if you're working for MQ. You're screwed either way! Seriously, though... - mrs.krabs

[ In Reply To ..]
My preference is put your own heading, just as you mentioned,for that body region. I think heart and cardiac are interchangeable. Only MQ auditors would disagree with you putting something there that wasn't dictated. So stupid!!!! Been in the biz long enough to know the doctors like us to correct their errors such as these in formatting, unless you get Mr. Persnickety and everything has to be done his perfect way.

Subheadings - Marine Mom

[ In Reply To ..]
Lungs
Back but probably Skin
Depends on what she is talking about the pelvis. If it is a pelvic exam, then I would put it under PELVIC if its a musculoskeletel pain issue, then maybe musculoskeletal.
Heart, cardiac, cardiovascular are all appropriate headings.

Unless this dictator is specific about the "order" in which they are placed such as verbatim dictated I would also put them in order

VITALS, GENERAL, HEENT, NECK, LUNGS, HEART, BACK, ABDOMEN, MUSCULOSKELETAL, PELVIC, EXTREMITIES, SKIN

Headings - Eleanor

[ In Reply To ..]
Not sure what you're testing for or doing, but whatever it is, they may just be trying to see if you use reasonable judgment. You know, like, not putting a foot exam in with the HEENT or something.

subheadings... - sw

[ In Reply To ..]
Specifically, she says, "Pelvis brim feels normal. No left upper quadrant mass. Abdomen is soft and nontender..." If it makes a difference, this is a woman with a leiomyosarcoma in the uterus. Would this go under PELVIC? Also, would left upper quadrant mass stay with the pelvis, or is this talking about the abdomen, even though she doesn't mention the abdomen until just afterward?

Thanks!

subheadings - Marine Mom

[ In Reply To ..]
I personally would put that under Abdomen, but mine is only one opinion

Mainly depends on what the client wants. Everyone is - different. NM

[ In Reply To ..]
x

physical exam headings - sm

[ In Reply To ..]
Definitely sounds like the "pelvis" part should go under ABDOMEN. For the mass, I would put it under BACK, unless it is a skin lesion, then SKIN. I have some docs who jump around like that and don't dictate subheadings at all, and I just type them as dictated...but not everyone is able to do that; depends on company/account. My company wants us to be consistent, otherwise it is pretty verbatim.

For a test, I would go ahead and put the subheadings since she did start off with LUNGS, however. It can be very confusing! You can try googling "physical examination headings" or some such combination, and find out what goes where. I used to sometimes google "what is in a musculoskeletal exam?" - or whatever it was I was looking for.

Generally accuracy of dictation is what most companies are looking for on tests, in my experience, but that is not to say that some aren't particular about style.

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