GENERAL MULTI-SYSTEM EXAMINATION WORKSHEET
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1 GENERAL MULTI-SYSTEM EXAMINATION WORKSHEET HPI ROS PFSH History Location Timing Allergic/Imm Eyes Musc/Sk el Past History Documentation of history of Problem Pertinent ROS = Related System Expanded General Multi-System Examination Constitutional Neurological Eyes Examination Palpation Heart Test Cranial Nerves Inspect Conjunc & Lids BP / Temp DTR Exam Pupil & Iris Exam BP Height Carotid Arteries Sensation Exam Optic Disc Exam : 1-5 Pulse RR Weight Abdominal Aorta Genitourinary bulleted ( ) Femoral Arteries Male Fe male Pedal Pulses Scrotum Genitalia Cervix Expanded : Gastrointestinal Extremities Penis Urethra Uterus 6 or > bulleted () Abd Exam: Mass/Tenderness Respiratory Prostate Bladder Adnexa Liver & Spleen Exam Respiratory Effort Musculoskeletal Detailed: 2 or > bulleted () Hernia Exam Percussion Chest Gait & Station Inspect/Palp Digits & Nails of 6 systems or 12 or > bulleted () in 2 or Anus, Perineum & Rectum Exam Palpation Chest Joints, Bones & Muscles 1 or > of 6 areas > systems Stool Occult (Indicated) Auscultation Lungs Inspect/Palpate Stability ENMT Skin ROM Musc Strength & Tone Inspect External Ears & Nose Inspect Skin & Sub-q Tiss Psychiatric all identified by a Aud Canal & Tymp Membr Exam Palpate Skin & Sub-q Tiss Judgement & Insight Memory bullet ( ) in at least 9 Assess Hearing Orientation TPP organ systems/body areas Inspect Nasal Mucosa, Sept & Turb Palp Lymph Nodes 2 or > Chest/Breast and document at least 2 Inspect Lips, Teeth & Gums Groin Exam Inspect Breasts bulleted ( ) from Oropharynx Exam Axillae Other Thyroid Exam Palp Breast & Axilla each of 9 systems/areas One self-limited or minor problem 2 or > self-limited/minor problems, 1 stable chronic 1 or > chronic illnesses with mild exacerbation, 2 or 1 or > chronic illnesses with severe exacerbation, or None Complexity Complexity Complexity EM Code Assignment
2 CARDIOVASCULAR EXAMINATION WORKSHEET HPI ROS PFSH History Problem Pertinent ROS = Related System Expanded Examination Constitutional BP / Temp BP Height Pulse RR Weight Gastrointestinal Abd Exam: Mass/Tenderness Liver & Spleen Exam Stool Occult (Indicated) ENMT Inspect Teeth, Gums & Palate Inspect Oral Mucosa Note Pallor/Cyanosis Palpation Heart BP 2 or > Extremities Carotid Arteries Abdominal Aorta Femoral Arteries Pedal Pulses Extremities: Peripheral Edema & Varicosities Musculoskeletal Back Exam: Kyphosis/Scoliosis Examine Gait/Ability to Exercise Assess Muscle Strength & Tone Eyes Inspect Conjunctivae & Lids Respiratory Respiratory Effort Auscultation Lungs Extremities Inspect & Palpate Digits & Nails Jugular Vein Exam Thyroid Exam Skin Inspect & Palpate Skin & Sub-q Tissue Orientation Time, Place & Person Examination : 1-5 bulleted ( ) Expanded : 6 or > bulleted ( ) all identified by a all in a box with a. or None Complexity Complexity Complexity E/M Code Assignment
3 EARS, NOSE, AND THROAT EXAMINATION WORKSHEET HPI ROS PFSH History Problem Pertinent ROS = Related System Expanded Ears, Nose, and Throat Examination Consitutional ENMT Eyes Examination Test Ocular Motility including Primary Gaze Alignment BP / Temp BP Height Pulse RR Weight Ability to Communicate Head and Face Inspect Head & Face Palpate & Percussion Face Salivary Glands Exam Assess Facial Strength Groin Axillae Other Otoscopic Exam: Auditory Canals & Tympanic Membranes Assess Hearing with Tuning Forks & Clinical Speech Reception Inspect External Ears & Nose Inspect Nasal Mucosa, Septum & Turbinates Inspect Lips, Teeth & Gums Oropharynx Exam: Mucosa, Palates, Tongue, Tonsils & Posterior Pharynx Inspect Pharyngeal Walls & Pyriform Sinuses Mirror Exam of Larynx Mirror Exam of Nasopharynx Exam Thyroid Exam Respiratory Inspection Chest Auscultation Lungs Test Cranial Nerves Orientation Time, Place & Person : 1-5 (bulleted ( ) Expanded : 6 or > bulleted ( ) all identified by a bullet ( ), document all in a box with a border and 1 element in each > stable chronic illnesses, new problem (uncertain acute complicated injury closed tx of fractures, therapeutic nuclear medicine or None EKG, UA, Ultrasound (no risk), CV imaging (no risk) e.g., arteriogram, angiogram, fluid from body cavity e.g., thoracentesis Complexity Complexity Complexity E/M Code Assignment
4 EYE EXAMINATION WORKSHEET HPI ROS PFSH History Problem Pertinent ROS = Related System Expanded Eye Examination Eyes Test Visual Acuity Gross Visual Field Testing by Confrontation Test Ocular Motility including Primary Gaze Alignment Inspection of Bulbar & Palpebral Conjunctivae Examination of Ocular Adnexae Examination of Pupils and Irises Slit Lamp Examination of Corneas Slit Lamp Examination of Anterior Chambers Slit Lamp Examination of Lenses Measurement of Intraocular Pressures (except in children and patients with trauma/infectious disease) Opthalmoscopic Exam through Dilated Pupils (unless contraindicated): Optic Discs Posterior Segments Orientation Time, Place & Person Examination : 1-5 bulleted ( ) Expanded : 6 or > bulleted ( ) Detailed: 9 or > bulleted ( ) all identified by a all in a box with a or None Complexity Complexity Complexity E/M Code Assignment
5 MALE GENITOURINARY EXAMINATION WORKSHEET HPI ROS PFSH History Problem Pertinent ROS = Related System Expanded Male Genitourinary Examination Constitutional GU Male Examination Inspect Anus & Perineum Exam Temp Genitalia Exam With/Without Specimen Thyroid Exam Height Collection: Weight Scrotum Respiratory : 1-5 Epididymides Respiratory Effort bulleted ( ) Testes Auscultation Lungs Urethral Meatus Expanded : Penis 6 or > bulleted ( ) Digital Rectal Exam Including: Prostate Gland Seminal Vesicles Sphincter Tone, Hemorrhoids & Rectal Masses BP / BP Pulse RR Gastrointestinal Abd Exam: Mass/Tenderness Hernia Exam Liver & Spleen Exam Stool Occult (Indicated) Axillae Groin Other Skin Inspect & Palpate Skin & Sub-q Tissue Orientation Time, Place & Person all identified by a all in a box with a or None Complexity Complexity Complexity E/M Code Assignment
6 FEMALE GENITOURINARY EXAMINATION WORKSHEET HPI ROS PFSH History Problem Pertinent ROS = Related System Expanded Female Genitourinary Examination Constitutional BP / Temp BP Height Pulse RR Weight Gastrointestinal Abd Exam: Mass/Tenderness Hernia Exam Liver & Spleen Exam Stool Occult (Indicated) Axillae Groin Other GU Female Includes at least 7 of the following 11 bulleted : Inspect & Palpate Breasts Digital Rectal Exam Pelvic Exam With/Without Specimen Collection: External Genitalia Urethral Meatus Urethra Bladder Vagina Cervix Uterus Adnexa Parametria Anus and Perineum Skin Inspect & Palpate Skin & Sub-q Tissue Exam Thyroid Exam Respiratory Respiratory Effort Auscultation Lungs Orientation Time, Place & Person Examination : 1-5 bulleted ( ) Expanded : 6 or > bulleted ( ) all identified by a all in a box with a or None Complexity Complexity Complexity E/M Code Assignment
7 HEMATOLOGICAL/LYMPHATIC/IMMUNOLOGIC EXAMINATION WORKSHEET HPI ROS PFSH History Problem Pertinent ROS = Related System Expanded Hematological//Immunologic Examination Constitutional Eyes Inspect Conjunctivae & Lids BP / BP Pulse RR Temp Height Weight Gastrointestinal Abd Exam: Mass/Tenderness Liver & Spleen Exam Axillae Groin Other Extremities Inspect & Palpate Digits & Nails Respiratory Respiratory Effort Auscultation Lungs ENMT Auditory Canal & Tympanic Membrane Exam Inspect Nasal Mucosa, Septum & Turbinates Inspect Teeth & Gums Oropharynx Exam Exam Thyroid Exam Head and Face Palpate & Percussion Face Orientation Time, Place & Person Skin Inspect & Palpate Skin & Sub-q Tissue Examination : 1-5 bulleted ( ) Expanded : 6 or > bulleted ( ) all identified by a all in a box with a or None Complexity Complexity Complexity E/M Code Assignment
8 MUSCULOSKELETAL EXAMINATION WORKSHEET HPI ROS PFSH History Problem Pertinent ROS = Related System Expanded Musculoskeletal Examination BP / BP Pulse RR Constitutional Temp Height Weight Musculoskeletal Gait & Station Exam Examine Joint(s), Bone(s), Muscle(s), & Tendon(s) of 4 of 6 areas: 1) Head & 2) Spine, Ribs & Pelvis 3) RUE 4) LUE 5) RLE 6) LLE Inspection, Percussion & Palpation Assess ROM Assess Stability Assess Muscle Strength & Tone (Count each Area/Extremity Assessed) Axillae Groin Other Skin Inspect & Palpate Skin & Sub-q Tissue Test Coordination DTR Exam & Nerve Stretch Test Sensation Exam Orientation Time, Place & Person Examination : 1-5 bulleted ( ) Expanded : 6 or > bulleted ( ) all identified by a all in a box with a or None Complexity Complexity Complexity E/M Code Assignment
9 NEUROLOGICAL EXAMINATION WORKSHEET HPI ROS PFSH History Problem Pertinent ROS = Related System Expanded Neurological Examination Constitutional BP / BP Pulse RR Temp Height Weight Eyes Optic Disc & Posterior Segment Exam Musculoskeletal Gait & Station Exam Assess Muscle Strength Assess Muscle Tone Carotid Arteries Neurological Orientation Time, Place & Person Recent & Remote Memory Attention Span & Concentration Language Fund of Knowledge Sensation Exam DTR Exam: Upper & er Extremities Test Coordination Test Cranial Nerves: 2 nd : Visual Acuity, Visual Fields, Fundi 3 rd, 4 th, 6 th : Pupils, Eye Movement 5 th : Facial Sensation, Corneal Reflexes 7 th : Facial Symmetry, Strength 8 th : Hearing with Tuning Fork, Whispered Voice & Finger Rub 9 th : Spontaneous or Reflex Palate Movement 11 th : Shoulder Shrug Strength 12 th : Tongue Protrusion Examination : 1-5 bulleted ( ) Expanded : 6 or > bulleted ( ) all identified by a all in a box with a or None Complexity Complexity Complexity E/M Code Assignment
10 PSYCHIATRIC EXAMINATION WORKSHEET HPI ROS PFSH History Problem Pertinent ROS = Related System Expanded Psychiatric Examination Constitutional Psychiatric Examination Description of Speech Description of Thought Processes BP / Temp BP Height Description of Associations Pulse RR Weight Description of Abnormal/Psychotic Thoughts : 1-5 Description of Judgment bulleted ( ) Orientation Time, Place & Person Recent & Remote Memory Expanded : Musculoskeletal Attention Span & Concentration 6 or > bulleted ( ) Gait & Station Exam Language Assess Muscle Strength & Tone Fund of Knowledge Detailed: 9 or > bulleted ( ) all identified by a all in a box with a or None Complexity Complexity Complexity E/M Code Assignment
11 RESPIRATORY EXAMINATION WORKSHEET HPI ROS PFSH History Problem Pertinent ROS = Related System Expanded Respiratory Examination Constitutional Respiratory Skin Examination Vital Signs Inspect & Palpate Skin & Sub-q BP / Temp Respiratory Effort Tissue BP Height Percussion Chest Extremities Pulse RR Weight Auscultation Lungs Inspect & Palpate Digits & Nails : 1-5 bulleted ( ) ENMT Inspect Nasal Mucosa, Septum, & Turbinates Inspect Teeth & Gums Oropharynx Exam Exam Thyroid Exam Jugular Vein Exam Gastrointestinal Abd Exam: Mass/Tenderness Musculoskeletal Gait & Station Exam Assess Muscle Strength & Tone Neuro-Psych Orientation Time, Place & Person Liver & Spleen Exam Axillae Groin Other Expanded : 6 or > bulleted ( ) all identified by a all in a box with a or None Complexity Complexity Complexity E/M Code Assignment
12 SKIN EXAMINATION WORKSHEET HPI ROS PFSH History Problem Pertinent ROS = Related System Expanded Skin Examination Constitutional BP / BP Pulse RR Temp Height Weight Eyes Inspect Conjunctivae & Lids Axillae Groin Other Skin Palpate Scalp & Inspect Hair of Scalp, Eyebrows, Face, Chest, Pubic Area & Extremities Palpate & Inspect Skin & Sub-q Tissue in 8 of 10 areas: Head, including Face Chest, including Breasts, Axillae Abdomen Genitalia, Groin, Buttocks Back RUE LUE RLE LLE Inspect Eccrine & Apocrine Glands of Skin and Sub-q Tissue ENMT Inspect Lips, Teeth & Gums Oropharynx Exam Extremities Inspect & Palpate Digits & Nails Gastrointestinal Liver & Spleen Exam Anus: Condyloma, Lesions Thyroid Exam Orientation Time, Place & Person Examination : 1-5 bulleted ( ) Expanded : 6 or > bulleted ( ) all identified by a all in a box with a or None Complexity Complexity Complexity E/M Code Assignment
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