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Documentation of the Medical Exam

Documentation of the Medical Exam

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A summary of the documentation requirements of the medical exam based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt from the Demystifying Medical Documentation presentation.
A summary of the documentation requirements of the medical exam based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt from the Demystifying Medical Documentation presentation.

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Published by: adultmedicalconsultants on Nov 01, 2008
Copyright:Traditional Copyright: All rights reserved

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01/11/2011

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Created byThe Lung Doctorfore-Medtools
Documentation of theDocumentation of theMedical ExamMedical Exam
 
Created byThe Lung Doctorfore-Medtools
Recognized Single Organ SystemsRecognized Single Organ Systems
CardiovascularEars, Nose, Mouth, ThroatEyesGenitourinary (Female)Genitourinary (Male)Hematologic/Lymphatic/ImmunologicMusculoskeletalNeurologicPsychiatricRespiratorySkin
Detailed
An extended exam of the affected body areaor organs/organ system and anothersymptomatic or related area
 
Detailed
An extended exam of the affected body areaor organs/organ system and anothersymptomatic or related area
Comprehensive
A general multi-system examA complete exam of an organ system andother related body areas or organ systems
Most levels require a minimum of a
Detailed 
Exam
 
Most levels require a minimum of a
Detailed 
Exam
 
Created byThe Lung Doctorfore-Medtools
MultiMulti--organ System Examorgan System Exam
Detailed 
3 vital signs
BP, sitting or standing
BP, supine
Pulse, rate and regularity
Respirations
Temperature
Height
Weight
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

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