Created by The Lung Doctor for e-Medtools

Documentation of the Documentation of the Medical ExamMedical Exam

Created by The Lung Doctor for e-Medtools

Recognized Single Organ SystemsRecognized Single Organ SystemsCardiovascularEars, Nose, Mouth, ThroatEyesGenitourinary (Female)Genitourinary (Male)Hematologic/Lymphatic/ImmunologicMusculoskeletalNeurologicPsychiatricRespiratorySkin

DetailedAn extended exam of the affected body area or organs/organ system and another symptomatic or related area

DetailedAn extended exam of the affected body area or organs/organ system and another symptomatic or related area

ComprehensiveA general multi-system examA complete exam of an organ system and

other related body areas or organ systems

Most levels require a minimum of a Detailed ExamMost levels require a minimum of a Detailed Exam

Created by The Lung Doctor for e-Medtools

MultiMulti--organ System Examorgan System ExamDetailed

≥3 vital signsBP, sitting or standingBP, supinePulse, rate and regularityRespirationsTemperatureHeightWeight

≥2 elements* of at least 6 organ systems or body areas examinedOR ≥1 element of at least 12 organ systems

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

*Refer to 1997 Guidelines for Evaluation & Management Services*Refer to 1997 Guidelines for Evaluation & Management Services

Created by The Lung Doctor for e-Medtools

Single Organ System ExamSingle Organ System Exam

DetailedDocument ≥12 elements* (NOT Eye and Psychiatric exams)

Eye and Psych exams document ≥9 elements

ComprehensiveDocument ALL elements*

*Refer to 1997 Guidelines for Evaluation & Management Services*Refer to 1997 Guidelines for Evaluation & Management Services

Created by The Lung Doctor for e-Medtools

Elements of Individual Organ SystemsElements of Individual Organ SystemsConstitutional

Vital signsGeneral appearance of patient

Nutrition, Body habitus, Development, Deformities, Grooming

EyesInspection of conjunctivae and lidsExam of pupils and irisesOphthalmoscopic exam of optic discs

Ears, Nose, Mouth and ThroatExternal inspection of ears and noseOtoscopic examAssessment of hearingInspection of nasal mucosa, septum, and turbinatesInspection of lips, teeth and gumsExam of oropharynx

NeckExam of neckThyroid

RespiratoryAssessment of effortPercussion of chestAuscultationPalpation of chest

CardiovascularPalpation of heartAuscultationCarotid artery examAbdominal aorta examFemoral arteries examPedal pulses examExtremities for edema or varicosities

Chest (Breasts)InspectionPalpation

GastrointestinalAbdominal examLiver and spleen examHernia presence or absenceAnus, perineum, rectum examStool for occult blood

1997 Guidelines for Evaluation & Management Services1997 Guidelines for Evaluation & Management Services

Created by The Lung Doctor for e-Medtools

Exam elements, continuedExam elements, continuedLymphatic

NeckAxillaGroinOther

MusculoskeletalGait and stationInspection, palpation digits and nailsExam of bones, joints, muscles AND 1 or more

Inspection or palpationRange of motion and presence/absence of painStabilityMuscle strength and tone

SkinInspectionPalpation

NeurologicCranial nervesDeep tendon reflexesSensation

PsychiatricJudgment and insightOrientation to person, time, placeMemory, recent and remoteMood and affect

Genitourinary

MaleScrotal contentsPenisDigital rectal exam of prostate gland

FemaleExternal genitaliaUrethraBladder examCervixUterusAdnexa/parametria

1997 Guidelines for Evaluation & Management Services1997 Guidelines for Evaluation & Management Services