Need help with Patient notes please

[FA2014]

Please help if you passed CS recently or received high score on ICE section.

1- Did you use any abbreviations in your denial section?
Is it ok to write on PN: *denies N/V, changes in GU AND GI symptoms*

or does it have to be *denies NAUSEA, VOMITING, changes in bowel movement and urination*?

2- Do we spell out all these terms for main ddx? Such as IBD - IBS - MDD -DVT - SLE- UTI - PKD - RCC - PSGN - BPH?

3- Is it ok to go for 2 ddx in all cases?

4- If one of the VS is abnormal do I copy and paste all of the VS on the PN? Do I have to mention tachycardia, bradycardia, HTN ..

5 - If pt wants letter to be excused from work due to joint pain, do I say after physical exam I may give you a letter. And if they are in pain on physical exam is it ok to say " I will come back and give you a letter since you are in pain"?
when do I deny the letter and how do I handle it?

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[CGB1078]

Please help if you passed CS recently or received high score on ICE section.

1- Did you use any abbreviations in your denial section?
Is it ok to write on PN: *denies changes in GU and GI symptoms*
or does it have to be *denies changes in bowel movement and urinary symptoms*?

If my PN only has GU, GI, N/V, abbreviation and rest all typed, will my PN grade go down?

2- Do we spell out all these terms for main ddx? Such as IBD - IBS - MDD -DVT - SLE- UTI - PKD - RCC - PSGN - BPH?

3- Is it ok to go for 2 ddx in all cases?

4- If one of the VS is abnormal do I copy and paste all of the VS on the PN? Do I have to mention tachycardia, bradycardia, HTN ..

5 - If pt wants letter to be excused from work due to joint pain, do I say after physical exam I may give you a letter. And if they are in pain on physical exam is it ok to say " I will come back and give you a letter since you are in pain"?
when do I deny the letter and how do I handle it?

2. i 'd just spell them out maybe you can get away with SLE, DVT, and UTI but i'd ake sure to spell out the rest

3. go for 3

4. try copy/pasting all the vital sigs real quick. practice it on the patient note software

5. say "mr. bla bla i understand you are in a lot of pain. Let me complete the physical exam, and once we are done i'll be more than happy to write you a letter for your employer. how does that sound?"

 

[FA2014]

2. i 'd just spell them out maybe you can get away with SLE, DVT, and UTI but i'd ake sure to spell out the rest

3. go for 3

4. try copy/pasting all vital sigs real quick. practice it on the patient note software

5. say "mr. bla bla i understand you are in a lot of pain. Let me complete the physical exam, and once we are done i'll be more than happy to write you a letter for your employer. how does that sound?"

Thank you so much! ...

#4---- Copy and paste all the VS even if all of them are normal instead of just writing WNL?

For #5----So at the end I can say that I will give you a note requesting for reduced work load instead of leave from work?

For #3 ---If I'm running out of time and I can either type the 3rd ddx or the PE, I plan on completing my PE instead of going for 3 ddx. What do you think? 3 ddx without PE or 2 with PE?