The general multisystem physical examination listed in the 1997 Documentation Guidelines is much more detailed than the body area/organ system physical examination listed in the 1995 Documentation Guidelines. In at least 10 sentences, please offer an explanation for why the general multisystem physical examination was created

What will be an ideal response?


Answer should include, but may not be limited to, the following:
? The 1995 body area/organ system physical examination provided an overview of the human anatomy, which limited the amount of specificity required in the documented physical examination. As a result, the documented physical examination only required simple documentation of any specific organ system or body area. This could create confusion about what was examined, because the documented findings of the physical examination identify how the performed physical examination relates to the nature of the presenting problem.
? The nature of the presenting problem identifies the level of risk posed to the patient by the disease or illness, while the type of the documented physical examination represents the complexity of the physical examination in relation to the nature of the presenting problem. However, since the 1995 body area/organ system physical examination guidelines do not provide clear numeric guidelines to determine objectively the complexity of the physical examination in relation to the nature of the presenting problem, clear, objective review of the documented physical examination may be problematic.
? In contrast with the 1995 body area/organ system physical examination, the general multisystem physical examination utilizes the evidentiary checklist to identify clearly the specific anatomy that was examined, as well as any normal, abnormal or unexpected findings. This provides a clearer correlation between the documented examination and the nature of the presenting problem.

Health Professions

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