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JoanneG

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Reply with quote  #1 
A provider performed an in-patient consultation and in the exam documentation on the note, stated HEENT exam is "unremarkable".  I feel that this implies he examined the systems and there were no findings, positive or negative.  Can I count these areas by the '95 exam guidelines? 
pjensen

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Reply with quote  #2 
Per the 95 guidelines, it is okay to say "normal" for organ systems which are normal.  Following this logic, you would give credit for two systems (eyes and ENMT) for the statement, "HEENT: unremarkable."
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