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Old 07-09-2012
Dr_Laura's Avatar
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Question Physical exam findings in Patient Note

Do you think that it's ok to write: None noted if there was nothing in the PE that helps us suspect the diagnosis.

It also says on the form that we can put negative findings to help support that diagnosis... What do you guys understand by that?

Let's say that my #1 diagnosis is PUD. and my hx findings are that the patient has pain while he eats.

#2 gastritis... Someone told me that I can write "no history of medication use" as my history finding because I am supporting my first diagnosis.

Is this right? Or do I write what supports #2 on the #2 history finding. What if there is nothing?

HELP administrators please!!!! :sorry:
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Old 07-10-2012
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To be honest, most of them will have something on the physical. I wouldn't just say that nothing was found because even the negatives will let the Dr (s) rating your note know that you did that. At least do the basics i.e., CV: RRR S1 S2 normal. Simple, but at least something.

Write down all the meds they tell you. Mostly always is has something to do with the case; aspirin for hearing loss....HCTZ for dizziness and indicative of HBP.

Remember that this is staged, they always have something relevant to say because it's only 10 minutes and they can't waste that time on irrelevant things....Everything they say (except when they ramble- on purposely) is relevant and fits somewhere in the history.

EDIT: I think you're talking about the new style. In that case, I'm not too sure. Maybe the mods have some insight. But still, you better believe that with this new format they have to make sure that there is something positive and something negative that supports or refuses the diagnosis. In real life, no. But in these cases..you can bet on it.
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