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 Abnormal
Fevers Myalgias 3 out of 3 Key Components Required Record three vital signs yes no
E/M Hx Exam MDM Time
Findings
Chills Muscle weakness
Night sweats Joint swelling 99201 PF PF SF 10
99202 EPF EPF SF 20 Conversant/NAD
Fatigue NSAID use
99203 Det Det Low 30 NECK yes no
Other: Other:
99204 Comp Comp Mod 45
Eyes no yes Skin no yes Non-tender, no masses
99205 Comp Comp High 60
Blurry vision Rash
Chief Complaint: No thryomegaly or nodules
Eye pain Pruritis
Discharge Sores HPI Brief: 1 - 3 HPI elements* Extended: 4 HPI elements* or status of 3 problems RESPIRATORY yes no
Dry eyes Nail changes
Normal respiratory effort
Decreased vision Skin thickening
Other: Other: Clear to auscultation
Ears/Nose/ CARDIOVASCULAR yes no
no yes Neurological no yes
Throat
Sore throat Migraines RRR, no MRGs
Tinnitus Numbness No peripheral edema
Bloody nose Ataxia
GASTROINTESTINAL* yes no
Hearing loss Tremors
Sinusitis Vertigo Abdomen soft, with no masses
Other: Other: No hepatosplenomegaly
Respiratory no yes Endocrine no yes
No hernias
Short of breath Excess thirst
Cough Polyuria
Guiaic negative (if indicated)
*HPI Elements: Location, Quality, Timing, Severity, Duration, Context, Modifying
Hemoptysis Cold intolerance GENITOURINARY (MALE)* yes no
Factors, Associated Signs and Symptoms
Wheezing Heat intolerance
Past Medical, Family and Social History Normal anus and perineum
Pleurisy Goiter
No scrotal lesions, cysts, rashes

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Other: Other: PMH
Cardiovascular no yes Psychiatric no yes FH Normal epididymis
Chest pain Depression Normal testes
PND Anxiety SH
Normal urethral meatus
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
No penile lesions or masses
Normal prostate; no nodules
Normal seminal vesicles
Normal rectal tone; no masses
SKIN yes no
m
Nausea Easy bruising No rashes, ulcers or lesions
Vomiting Bleeding diathesis
LYMPHADENOPATHY? yes no
Diarrhea Blood clots
Neck Axillae Groin
Hematemesis Swollen glands
Melena Lymphedema NEURO/PSYCHIATRIC yes no
Appropriate affect
Sa

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

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