WebThe physician conducts a comprehensive examination focused on the patient's chief complaint. The uterus is found to be soft and involuted. There is cervical motion tenderness and significant abdominal tenderness on palpation. A … WebHe performs a general multisystem comprehensive exam of eight - organ - systems . The physician orders labs to be performed in the office including carbon dioxide , chloride , potassium and sodium . The nurse performs venipuncture to obtain the blood sample . The physician diagnose the patient with dehydration and instructs the mother to ...
single organ system examination - definition of single
WebDec 16, 2024 · A comprehensive examination is a complete general multi-system examination (eight or more organ systems) or a complete examination of a single organ system, the 1995 E/M Documentation Guidelines state. The guidelines neglect, however, … WebExpanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements: Chief complaint (CC); ... -- a general multi-system examination or complete examination of a single organ system. For purposes of examination, the following body areas are recognized: Head, including the face Neck bing christmas films quiz 9
How to Document the Physical Exam
WebProblem. 8CTE. A patient is admitted with nausea and vomiting. She has lost a great deal of fluid and is dehydrated. The physician orders IV fluids and nothing by mouth. The patient is already very thin. Give two possible nursing diagnoses for this patient, using diagnostic labels only, and etiology if possible. WebTwo bullets from EACH of nine organ systems Example Vitals: 120/80, 88, 98.6 General appearance: NAD, conversant Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA HENT: Atraumatic; oropharynx clear with moist mucous membranes and no mucosal ulcerations; normal hard and soft palate cytometric beads assay