Review of Systems Physical Exam (Each check box = 1 bullet)

Patient: _____________________ Date: __________

Constitutional no yes Musculoskeletal no yes CONSTITUTIONAL*
Weight loss Arthralgias New Office Patient Record three vital signs yes no
Abnormal
Fevers Myalgias 3 out of 3 Key Components Required Findings
Chills Muscle weakness E/M Hx Exam MDM Time
Night sweats Joint swelling 99201 PF PF SF 10 Well developed, well nourished
Fatigue NSAID use
99202 EPF EPF SF 20 Conversant with normal voice quality
99203 Det Det Low 30
Other: Other: EYES yes no
99204 Comp Comp Mod 45
Eyes no yes Skin no yes EOMI, normal gaze alignment
99205 Comp Comp High 60
Blurry vision Rash
ENMT* yes no
Eye pain Pruritis Chief Complaint:
Discharge Sores Canals patent; TMs intact and pearly
HPI Brief: 1 - 3 HPI elements* Extended: 4 HPI elements* or status of 3 problems
Dry eyes Nail changes Pneumotoscopy: normal TM mobility
Decreased vision Skin thickening Normal clinical hearing exam
Other: Other: Normal appearance of ears and nose
Ears/Nose/
Throat
no yes Neurological no yes Normal nasal mucosa/turbinates
Sore throat Migraines Normal lips, teeth and gums
Tinnitus Numbness Normal oropharynx/palates/tongue
Bloody nose Ataxia Normal pharyngeal walls & piriforms
Hearing loss Tremors
Normal mirror exam of larynx,
Sinusitis Vertigo epiglottis, false cords, true cords
Other: Other:
Normal mirror exam of nasopharynx
Respiratory no yes Endocrine no yes
Short of breath Excess thirst HEAD and FACE* yes no
Cough Polyuria Normal appearance of head and face
Hemoptysis Cold intolerance
*HPI Elements: Location, Quality, Timing, Severity, Duration, Context, Modifying
No sinus tenderness
Factors, Associated Signs and Symptoms
Wheezing Heat intolerance Normal salivary glands
Past Medical, Family and Social History
Pleurisy Goiter
Normal facial strength

e
Other: Other: PMH
Cardiovascular no yes Psychiatric no yes FH NECK* yes no
Chest pain Depression FROM; no masses; trachea midline
PND Anxiety SH
No thryomegaly, nodules or masses
Palpitations
Edema
Orhtopnea
Syncpe
Other:
Gastrointestinal no yes
Anti-depressants
Alcohol abuse
Drug abuse
Insomnia
Other:
Hem/Lymphatic no yes
Problem Focused: Brief HPI, no ROS/PFSH
Detailed: Ext HPI, 2 - 9 ROS, 1/3 PFSH
pl
Level of History Documented
EPF: Brief HPI, 1 ROS, no PFSH
Comp: Ext HPI, 10 ROS, 3/3 PFSH
Data Reviewed
RESPIRATORY
Normal respiratory effort
Clear to auscultation
CARDIOVASCULAR
yes no

yes no
m
RRR, no MRGs
Nausea Easy bruising
No peripheral edema, pulses intact
Vomiting Bleeding diathesis
LYMPHADENOPATHY? yes no
Diarrhea Blood clots
Hematemesis Swollen glands
Neck Axillae Groin
Melena Lymphedema NEURO/PSYCHIATRIC yes no
Sa

Other: Other: Appropriate affect

Genitourinary no yes Allrgic/Immun no yes A&OX3
Hematuria Allergic rhinitis
Cranial nerves II - XII intact
Dysuria Hay fever Data Points
Hesitancy Asthma Problem Focused Exam: 1 - 5 bullets
Review Review and/ Review and/or order Discuss Review any Order Expanded Problem Focused Exam : 6 - 11 bullets
Summarize
Incontinence Positive PPD and/or or order X- medical test (PFTs, test with image, tracing, old
old records Detailed Exam: 12 bullets
UTIs Hives order labs rays EKG, echo, cath) MD specimen records
Comprehensive Exam: All bullets from starred systems plus
Other: Other: 1 1 1 1 2 1 2 one bullet from EVERY other system

4 3 1 2 1 Assessment (Assign problem points on the left.) Plan

99201
99202
Self-limited or minor (max 2)
New, further w/u is planned

Established, stable
New, no further w/u planned

Established, not controlled

99203

MDM Prob Pts Data Pts Risk 99204

SF ≤1 1 Min 99205
Low 2 2 Low
Mod 3 3 Mod
High ≥4 4 High ______________________________________
Only 2 out of 3 MDM dimensions required Signature
Minimal Risk Low Risk Moderate Risk High Risk
•One self limited problem • Two self-limited problems • Mild exacerbation of one chronic illness • Severe exacerbation of chronic illness
(e.g., cold, insect bite) • One stable chronic illness • Two stable chronic illnesses • Illness with threat to life or bodily function
• Acute uncomplicated illness • Undiagnosed new problem • Abrupt change in neurological status (e.g., TIA/weakness)
(e.g., cystitis/rhinitis) • Acute illness with systemic symptoms • Parenteral controlled substances
• OTC drugs (e.g., pyelonephritis, colitis) • Decision for DNR or to de-escalate care
• Prescription drug management • Drugs requiring intensive monitoring for toxicity