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TABLE OF CONTENTS
Foreword...................................................................................................................1
Introduction................................................................................................................2
What Is Documentation and Why Is it Important?............................................2
What Do Payers Want and Why?....................................................................2
General Principles of Medical Record Documentation................................................. 3
Documentation of E/M Services ................................................................................ 4
Documentation of History............................................................................................5
Chief Complaint (CC) ................................................................................... 6
History of Present Illness (HPI)........................................................................7
Review of Systems (ROS).............................................................................. 8
Past, Family and/or Social History (PFSH)...................................................... 9
Documentation of Examination....................................................................................10
General Multi-System Examinations................................................................11
Single Organ System Examinations..................................................................12
Content and Documentation Requirements......................................................13
General Multi-System Examination......................................................13
Cardiovascular Examination.............................................................. 18
Ear, Nose and Throat Examination..................................................... 20
Eye Examination................................................................................ 23
Genitourinary Examination.................................................................. 25
Hematologic/Lymphatic/Immunologic Examination.............................. 29
Musculoskeletal Examination.............................................................. 31
Neurological Examination................................................................... 34
Psychiatric Examination...................................................................... 37
Respiratory Examination.................................................................... 39
Skin Examination................................................................................ 41
Documentation of the Complexity of Medical Decision Making.....................................43
Number of Diagnoses or Management Options............................................... 44
Amount and/or Complexity of Data to Be Reviewed....................................... 45
Risk of Significant Complications, Morbidity, and/or Mortality......................... 46
Table of Risk.................................................................................................. 47
Documentation of an Encounter Dominated by Counseling or Coordination of Care..... 48
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