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• Welcome
• Table of Contents
• Forward
• Introduction
  • What Is Documentation and Why Is it Important?
  • What Do Payers Want and Why?
• General Principals of Documentation
• Documentation of E&M Services
• Documentation of History
  • Chief Complaint (CC)
  • History of present illness (HPI)
  • Review of systems (ROS)
  • Past, family and/or social history (PFSH)
• Documentation of Examination
  • General Multi-System Examinations
  • Single Organ System Examinations
  • Content and Documentation Requirements
  • General Multi-System Examination
  • Cardiovascular Exam
  • Ear, Nose, and Throat Exam
  • Eye Exam
  • Genitourinary Exam
  • Hematologic/Lymphatic/Immunologic Exam
  • Musculoskeletal Exam
  • Neurological Exam
  • Psychiatric Exam
  • Respiratory Exam
  • Skin Exam
• Documentation of the Complexity of Medical Decision Making
  • Documentation of the Complexity of Medical Decision Making
  • Number of Diagnoses or Management Options
  • Amount and/or Complexity of Data to Be Reviewed
  • Risk of Significant Complications, Morbidity, and/or Mortality
  • Table of Risk
  • Documentation of Counseling or Coordination of Care