CS - patient note

[anothermed]

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Hi, I can't remember where, but I thought that when the door notes say "Do no perform physical exam", you are to leave the examination part of the patient note blank. Is this true even for a psych case, where, you don't do a traditional physical exam, but you can do a mini mental state without touching the patient. In this case, would you leave the examination part of the patient note blank still?? I did...I hope I didn't fail because of this 🙁

 

[Hoo\/er]

If the door info says to not perform the physical exam, I would still include the relevant history, ROS, and DDx on the patient note. I wouldn't leave the entire note blank.

 

[anothermed]

Hi, sorry I meant that I filled in the History section, DDx, and Investigations, but I left the Examination section completely blank. Is this the right approach?

Thank you.

 

[Hoo\/er]

Oops, I misread your post. Yes, you leave the PE section of the note blank or write N/A under the section.