Created by The Lung Doctor

Single Organ System ExamSingle Organ System Exam

Respiratory

Created by The Lung Doctor

Single Organ System ExamSingle Organ System ExamRespiratoryRespiratory

Comprehensive LevelPerform and document ALL

elements in the following organ systems Constitutional ENT Inspection Neck Respiratory Cardiovascular Gastrointestinal Lymphatic

Perform and document at least 1 element in each of the following

MusculoskeletalExtremitiesSkinNeurologic

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Single Organ System ExamSingle Organ System ExamRespiratoryRespiratory

ConstitutionalDocument at least 3 vital signs as follows

Blood Pressure – Sitting OR Standing

Blood Pressure– Lying

Pulse– Rate AND Regularity

Temperature Height Weight

Note: May be measured and recorded by ancillary staff

Created by The Lung Doctor

Single Organ System ExamSingle Organ System ExamRespiratoryRespiratory

Ears, Nose, Mouth, ThroatInspection of nasal mucosa, septum,

turbinatesInspection of teeth and gumsExamination of oropharynx

Oral mucosa, hard and soft palates, tongue, tonsils, and posterior pharynx

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Single Organ System ExamSingle Organ System ExamRespiratoryRespiratory

NeckExamination of neck

Masses, overall appearance, symmetry, tracheal position, crepitus

Examination of thyroid Enlargement, tenderness, mass

Examination of jugular veins Distension, a, v or cannon a waves

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Single Organ System ExamSingle Organ System ExamRespiratoryRespiratory

RespiratoryInspection of chest with notation of symmetry and

expansionAssessment of respiratory effort

Intercostal retractions, accessory muscle use, and diaphragmatic movement

Percussion of chest Dullness, flatness, hyperresonance

Palpation of chest Tactile fremitus

Auscultation of lungs Breath sounds, adventitious sounds, rubs

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Single Organ System ExamSingle Organ System ExamRespiratoryRespiratory

CardiovascularAuscultation of heart sounds, abnormal

sounds and murmursExamination of peripheral vascular system by

observation and palpation Swelling and varicosities Pulses, temperature, edema, tenderness

Created by The Lung Doctor

Single Organ System ExamSingle Organ System ExamRespiratoryRespiratory

Gastrointestinal (Abdominal)

Examination of abdomen with notation of presence or absence of masses or tenderness

Examination of liver and spleen

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Single Organ System ExamSingle Organ System ExamRespiratoryRespiratory

LymphaticPalpation of lymph nodes

Neck Groin Axilla Other location

Note: Exam of at least 2 locations must be documented

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Single Organ System ExamSingle Organ System ExamRespiratoryRespiratory

Perform and document at least 1 of the following

MusculoskeletalAssessment of muscle strength and tone with

notation of any atrophy and abnormal movements Flaccid, cogwheel, spastic

Examination of gait and station

Created by The Lung Doctor

Single Organ System ExamSingle Organ System ExamRespiratoryRespiratory

Perform and document at least 1 of the following

ExtremitiesInspection and palpation of digits and nails

Clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes

Created by The Lung Doctor

Single Organ System ExamSingle Organ System ExamRespiratoryRespiratory

Perform and document at least 1 of the following

SkinInspection and/or palpation of skin and

subcutaneous tissue Rashes, lesions, ulcers

Created by The Lung Doctor

Single Organ System ExamSingle Organ System ExamRespiratoryRespiratory

Perform and document at least 1 of the following

Neurological/PsychiatricBrief assessment of mental status

Include orientation to person, time and place Include mood and affect

– Anxiety, depression, agitation