Hi All,

I have a few questions about the exam..

1- Physical Findings that can't be simulated e.g. in a patient with sore throat - they will have normal HEENT exam... so although we would normally expect a red pharynx + or - other findings like exudates, lymphadenopathy, etc.. We should write what we find.. So is the statement below correct?
"HEENT: NC/AT, Nose, mouth, pharynx WNL. TMs intact."
"Neck: Supple. No lymphadenopathy."

2- FA doesn't have some common abbreviations like:
"Gen: NAD"
"Lungs: CTAB"
"CVS: RRR +S1, +S2, no M/R/G"
"Abd: Soft, ND, NT, +BS, no masses."
"Neuro: A&O x3. CN 2-12 grossly intact"

Is the above documentation acceptable, if you in fact did those exams..??

Thank you

BUMP..

Anyone with any answers/help.. please?

anyone?