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Two physical exams? - app
Posted: Apr 19, 2010
I transcribing a dictation where "physical examination" was already dictated after the history of present illness and before the past medical history. Now she's dictated it again after the review of systems. Is it possible that the first one should have gone under the history of present illness heading? Also, in her review of systems, she numbers each heading...should I transcribe it as such or leave the numbers out?
Rebarding the number of ROS, that is per the - kl
[ In Reply To ..]client's wishes. Need to check with them/your supervisor. As for 2 physical exams, sometimes I have them dictate a physical with the HPI without headings, and then later in teh report the actual physical. I would leave as it, especially if there are differences and send it to QA and let them make the decision.
***should be regarding. - kl - NM
[ In Reply To ..]x
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