You Be The Coder: September

September 4, 2015

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)

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