This is a question about documenting the physical exam.
Our Clinical treatment forms are templates that have "check" boxes for ROS, PFSH, Physical Exam Body Areas/Organ Systems. There are also diagrams of the body since we are Dermatology specialty.
When the provider is documenting the physical exam, can he/she just draw a line to the body part on the diagram and write what the finding is without checking the appropriate box for body area/organ system?
OR
does the provider have the check the appropriate box under the physical exam section indicating which body area or organ system was examined?
Any help is appreciated. Thank you.