You Be The Coder: September

How many physical examination elements can you extract from this documentation?

• VS: 124/80, Pulse: 74, Weight: 174 pounds
• CTA
• A&Ox3
• No CCE

Answer below:

Answer: Six

1. Constitutional – Vital Signs
2. Respiratory – Clear to Auscultation (CTA)
3. Psych – Alert and Oriented X 3 (A&Ox3). No CCE; (Clubbing, Cyanosis, Edema)
4. Musculoskeletal (Clubbing)
5. Cyanosis (Skin)
6. Edema (Cardiovascular or Lymphatic)