Listing items under the Physical Exam heading

Forums Healthcare Documentation Course Course Support Listing items under the Physical Exam heading

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  • Rhondamcart
    Participant

    So I am really frustrated by the Physical Exam heading. I can’t figure out when to list the different areas examined followed by a colon and when to transcribe everything into a paragraph. Does anyone have any idea on an easy way to know when to list and when not to list?

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  • Laurie Monks
    Participant

    Hi Rhondamcart!

    You need to look at the sentences within the physical exam. Similar to deciding if you have a major heading or a sentence at the start of each paragraph, you need to decide if each sentence is a regular sentence or has a subheading at the start.

    The key to this is to look to see if a verb was dictated that applies to your ‘potential subheading.’ Here are a few examples:

    Extremities show 2+ edema. (Is this a subheading or sentence? The verb ‘show’ applies to your potential subheading “extremities,” so this should be formatted as a regular sentence.)

    Extremities edematous with excoriations on the left lateral calf. (Is this a subheading or sentence? There is no verb which applies to ‘extremities,’ so this should become a subheading.)
    Correction = Extremities: Edematous with excoriations on the left lateral calf.

    As soon as you have a subheading within an exam, you need to change the formatting of the entire exam to stacked/list format. This means that each new section of the exam should have a line of its own.

    Please let us know if you have any questions!

    Laurie Monks, Instructor

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    Rhondamcart
    Participant

    Wow! Thanks Laurie!! That totally makes sense. I can’t tell you how frustrated it made me. And of course I always picked the wrong format. Lol!

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    Rhondamcart
    Participant

    So I guess my next question is after deciding whether it is a subheading or not, should you separate each individual area examined and display them in a list format, use a paragraph format for everything under the Physical Exam heading, or use sentences for the appropriate areas and then list the other parts on a new line?

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    Hi Rhonda,

    If you have a subheading in the physical exam section, then the whole section needs to be in a stacked format.

    I suggest checking out the examples in the account specifics on physical exam formatting.

    Hope this clears things up for you!

    Regards,

    Lisa

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