Documentation of the

Medical Exam

Created by The Lung Doctor for e-Medtools

Recognized Single Organ Systems
Cardiovascular
Ears, Nose, Mouth, Throat
Detailed
Detailed
Eyes Anextended
An extendedexam
examof ofthe
theaffected
affectedbody
bodyarea
area
Genitourinary (Female) ororgans/organ
or organs/organsystem
systemandandanother
another
symptomaticor
symptomatic orrelated
relatedarea
area
Genitourinary (Male)
Hematologic/Lymphatic/Immunologic
Musculoskeletal Comprehensive
Neurologic A general multi-system exam
A complete exam of an organ system and
Psychiatric other related body areas or organ systems
Respiratory
Skin
Mostlevels
Most levelsrequire
requireaaminimum
minimumof
ofaaDetailed
DetailedExam
Exam

Created by The Lung Doctor for e-Medtools

 Multi-organ System Exam
Detailed
≥3 vital signs
ƒ BP, sitting or standing
ƒ BP, supine
ƒ Pulse, rate and regularity
ƒ Respirations
ƒ Temperature
ƒ Height
ƒ Weight
≥2 elements* of at least 6 organ systems or body areas examined
OR ≥1 element of at least 12 organ systems

Comprehensive
≥2 elements* in at least 9 organ systems or body areas

*Referto
*Refer to1997
1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services

Created by The Lung Doctor for e-Medtools

 Single Organ System Exam
Detailed
™ Document ≥12 elements* (NOT Eye and Psychiatric exams)
™ Eye and Psych exams document ≥9 elements

Comprehensive
™ Document ALL elements*

*Referto
*Refer to1997
1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services

Created by The Lung Doctor for e-Medtools

 Elements of Individual Organ Systems
Constitutional Cardiovascular
¾ Vital signs ¾ Palpation of heart
¾ General appearance of patient ¾ Auscultation
¾ Nutrition, Body habitus, Development, Deformities,
Grooming ¾ Carotid artery exam
Eyes ¾ Abdominal aorta exam
¾ Inspection of conjunctivae and lids ¾ Femoral arteries exam
¾ Exam of pupils and irises ¾ Pedal pulses exam
¾ Ophthalmoscopic exam of optic discs ¾ Extremities for edema or varicosities
Ears, Nose, Mouth and Throat Chest (Breasts)
¾ External inspection of ears and nose ¾ Inspection
¾ Otoscopic exam ¾ Palpation
¾ Assessment of hearing Gastrointestinal
¾ Inspection of nasal mucosa, septum, ¾ Abdominal exam
and turbinates ¾ Liver and spleen exam
¾ Inspection of lips, teeth and gums ¾ Hernia presence or absence
¾ Exam of oropharynx ¾ Anus, perineum, rectum exam
Neck ¾ Stool for occult blood
¾ Exam of neck
¾ Thyroid
1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services
Respiratory 1997
¾ Assessment of effort
¾ Percussion of chest
¾ Auscultation
¾ Palpation of chest
Created by The Lung Doctor for e-Medtools
 Exam elements, continued
Lymphatic Psychiatric
¾ Neck ¾ Judgment and insight
¾ Axilla ¾ Orientation to person, time, place
¾ Groin ¾ Memory, recent and remote
¾ Other ¾ Mood and affect
Musculoskeletal Genitourinary
¾ Gait and station
¾ Inspection, palpation digits and nails Male
¾ Exam of bones, joints, muscles AND 1 ¾ Scrotal contents
or more ¾ Penis
¾ Inspection or palpation ¾ Digital rectal exam of prostate gland
¾ Range of motion and
presence/absence of pain
¾ Stability Female
¾ Muscle strength and tone ¾ External genitalia
Skin ¾ Urethra
¾ Inspection ¾ Bladder exam
¾ Palpation ¾ Cervix
Neurologic ¾ Uterus
¾ Cranial nerves ¾ Adnexa/parametria
¾ Deep tendon reflexes
¾ Sensation 1997Guidelines
1997 Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services

Created by The Lung Doctor for e-Medtools