Breast chart notes


Examination of external genitalia e. Making sure your notes are organized as a reviewer would like them can't hurt, although if it requires changing your documentation habits, it can slow you down a little until you're used to it. Use an outline format. Published April 1, Pelvic examination with or without specimen collection for smears and cultures , including:
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Exam Documentation: Charting Within the Guidelines

BS clr to percussion and auscultation. Dimpling, puckering, or bulging of the skin A nipple that has changed position or an inverted nipple pushed inward instead of sticking out Redness, soreness, rash, or swelling. Get immediate access, anytime, anywhere. Pelvic examination with or without specimen collection for smears and cultures , including: Detailed — should include performance and documentation of at least two bulleted elements from each of six organ systems or body areas OR performance and documentation of at least 12 bulleted elements ; the 12 elements must be drawn from two or more organ systems or body areas;.
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Breast Self-Exam

Measurement of any three of the following seven vital signs: Last modified on August 16, at For example, a study of nearly , women in Russia and China reported that breast self-exam does not reduce breast cancer mortality and may even cause harm by prompting unnecessary biopsies removal and examination of suspicious tissue. To qualify for a given level, your exam must meet the following content and documentation requirements these are summarized in the table " Exam content and documentation requirements ":. The first alternative at least two elements from each of six systems or body areas is just a special case of the second. Subdivide each of the major sections appropriately.
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Description:In the example discussed above, the physician performed and documented at least two elements from each of the following five body areas or organ systems: Just remember that this is only one possibility. Yes, it's complicated, but don't make it harder than it has to be. A comprehensive multisystem exam would pretty clearly be inappropriate given the clinical situation and chief complaint, but just by way of illustration, it would also require the physician to document at least two elements from four of the following additional body areas or organ systems to bring the total number of body areas or organ systems to nine: Immediate access to this article. If you note an abnormal finding, be specific. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.

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