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Documentation of the Respiratory Single Organ System Exam

Documentation of the Respiratory Single Organ System Exam

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A summary of the medical documentation requirements for the respiratory single organ system exam based on the 1997 Evaluation and Management Systems Guidelines.
A summary of the medical documentation requirements for the respiratory single organ system exam based on the 1997 Evaluation and Management Systems Guidelines.

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Published by: adultmedicalconsultants on Nov 02, 2008
Copyright:Traditional Copyright: All rights reserved

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09/07/2012

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Single Organ System ExamSingle Organ System Exam
Respiratory
 
Single Organ System ExamSingle Organ System Exam
RespiratoryRespiratory
Comprehensive Level
Perform and document ALLelements in the following organ systems
Constitutional
ENT Inspection
Neck
Respiratory
Cardiovascular 
Gastrointestinal
Lymphatic
Perform and document at least 1element in each of the following 
Musculoskeletal
Extremities
Skin
Neurologic
 
Single Organ System ExamSingle Organ System Exam
RespiratoryRespiratory
Constitutional
Document 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 

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