| Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs | |
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Refer to data section (table below) in order to quantify. After reviewing the medical record documentation, identify the level of examination. Circle the level of examination within the appropriate grid in Section 5 (Page 3).
Performed and Documented |
Level of Exam |
One to five bullets |
Problem Focused |
Six to eleven bullets |
Expanded Problem Focused |
Twelve or more bullets |
Detailed |
In the first table below, if at least one bullet is applicable to each system/body area AND all bullets in the second table are applicable, then the level of exam is comprehensive. |
Comprehensive | (Circle the bullets that are documented.) NOTE: For the descriptions of the elements of examination containing the words "and", "and/or", only one (1) of those elements must be documented.
System/Body
Area |
Elements of Examination |
Extremities |
Inspection and palpation of digits and nails (e.g., clubbing, cyanosis,
inflammation, petechiae, ischemia, infections, nodes) |
Eyes |
Inspection of conjunctivae and lids |
Head and Face |
Palpation and/or percussion of face with notation of presence or absence of
sinus tenderness |
Lymphatic |
Palpation of lymph nodes in neck, axillae, groin and/or other location |
Neck |
Examination of neck (e.g., masses, overall appearance, symmetry, tracheal
position, crepitus) Examination of thyroid (e.g., enlargement, tenderness, mass) |
Neurological/
Psychiatric |
Brief assessment of mental status including: Orientation to time, place and person Mood and affect (e.g., depression, anxiety, agitation) |
Skin |
Inspection and/or palpation of skin and subcutaneous tissue (e.g., rashes,
lesions, ulcers, ecchymoses, bruises) |
System/Body
Area |
Elements of Examination |
Cardiovascular |
Auscultation of heart with notation of abnormal sounds and murmurs Examination of peripheral vascular system by observation (e.g., swelling,
varicosities) and palpation (e.g., pulses, temperature, edema, tenderness) |
Constitutional |
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 (e.g., development, nutrition, body habitus,
deformities, attention to grooming) |
Ears, Nose, Mouth and Throat |
Otoscopic examination of external auditory canals and tympanic membranes Inspection of nasal mucosa, septum and turbinates Inspection of teeth and gums Examination of oropharynx (e.g., oral mucosa, hard and soft palates, tongue,
tonsils, posterior pharynx) |
Gastrointestinal
(Abdomen) |
Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen |
Respiratory |
Assessment of respiratory effort (e.g., intercostal retractions, use of accessory
muscles, diaphragmatic movement) Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs) | Note: The Chest (Breasts), Genitourinary and Musculoskeletal systems/body areas are not considered integral parts of this specialty exam. (Enter the number of circled bullets in the boxes below. Then circle the appropriate level of care.)
One to Five
Bullets |
Six to Eleven
Bullets |
Twelve or
more Bullets |
Answer the following two questions. If both
answers are "yes," the appropriate level of
exam is comprehensive. Was at least one bullet in each system/body area
documented in the first table? Yes No Was each bullet in the second table documented? Yes No |
Problem Focused |
Expanded Problem Focused |
Detailed |
Comprehensive | 10224 11/97
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