CONTENT AND DOCUMENTATION REQUIREMENTS
General Multi-System Examination
System/Body Area
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Elements of Examination
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Constitutional
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• Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
• General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
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Eyes
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• Inspection of conjunctivae and lids
• Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry)
• Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)
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Ears, Nose, Mouth and Throat
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• External inspection of ears and nose (eg, overall appearance, scars, lesions, masses)
• Otoscopic examination of external auditory canals and tympanic membranes
• Assessment of hearing (eg, whispered voice, finger rub, tuning fork)
• Inspection of nasal mucosa, septum and turbinates
• Inspection of lips, teeth and gums
• Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx
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Neck
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• Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)
• Examination of thyroid (eg, enlargement, tenderness, mass)
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Respiratory
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• Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)
• Percussion of chest (eg, dullness, flatness, hyperresonance)
• Palpation of chest (eg, tactile fremitus)
• Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
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Cardiovascular
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• Palpation of heart (eg, location, size, thrills)
• Auscultation of heart with notation of abnormal sounds and murmurs
Examination of:
• carotid arteries (eg, pulse amplitude, bruits)
• abdominal aorta (eg, size, bruits)
• femoral arteries (eg, pulse amplitude, bruits)
• pedal pulses (eg, pulse amplitude)
• extremities for edema and/or varicosities
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Chest (Breasts)
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• Inspection of breasts (eg, symmetry, nipple discharge)
• Palpation of breasts and axillae (eg, masses or lumps, tenderness)
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Gastrointestinal
(Abdomen)
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• Examination of abdomen with notation of presence of masses or tenderness
• Examination of liver and spleen
• Examination for presence or absence of hernia
• Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
• Obtain stool sample for occult blood test when indicated
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Genitourinary
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MALE:
• Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass)
• Examination of the penis
• Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness)
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FEMALE:
Pelvic examination (with or without specimen collection for smears and cultures), including
• Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
• Examination of urethra (eg, masses, tenderness, scarring)
• Examination of bladder (eg, fullness, masses, tenderness)
• Cervix (eg, general appearance, lesions, discharge)
• Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support)
• Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
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Lymphatic
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Palpation of lymph nodes in two or more areas:
• Neck
• Axillae
• Groin
• Other
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Musculoskeletal
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• Examination of gait and station
• Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)
Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The examination of a given area includes:
• Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions
• Assessment of range of motion with notation of any pain, crepitation or contracture
• Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
• Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements
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Skin
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• Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)
• Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening)
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Neurologic
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• Test cranial nerves with notation of any deficits
• Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski)
• Examination of sensation (eg, by touch, pin, vibration, proprioception)
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Psychiatric
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• Description of patient’s judgment and insight
Brief assessment of mental status including:
• orientation to time, place and person
• recent and remote memory
• mood and affect (eg, depression, anxiety, agitation)
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Content and Documentation Requirements
Level of Exam
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Perform and Document:
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Problem Focused
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One to five elements identified by a bullet.
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Expanded Problem Focused
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At least six elements identified by a bullet.
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Detailed
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At least two elements identified by a bullet from each of six areas/systems OR at least twelve elements identified by a bullet in two or more areas/systems.
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Comprehensive
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Perform all elements identified by a bullet in at least nine organ systems or body areas and document at least two elements identified by a bullet from each of nine areas/systems.
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