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
Record three vital signs yes no
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 Conversant/NAD
Fatigue NSAID use
99202 EPF EPF SF 20
EYES yes no
99203 Det Det Low 30
Other: Other:
99204 Comp Comp Mod 45 Normal conjunctivae and lids
Eyes no yes Skin no yes
99205 Comp Comp High 60 ENMT yes no
Blurry vision Rash
Eye pain Pruritis Chief Complaint: Normal teeth, gums and palate
Discharge Sores HPI Brief: 1 - 3 HPI elements* Extended: 4 HPI elements* or status of 3 problems No mucosal pallor or cyanosis
Dry eyes Nail changes NECK yes no
Decreased vision Skin thickening No JVD
Other: Other:
No thryomegaly, nodules or masses
Ears/Nose/
no yes Neurological no yes RESPIRATORY* yes no
Throat
Sore throat Migraines Normal respiratory effort
Tinnitus Numbness
Clear to auscultation
Bloody nose Ataxia
Hearing loss Tremors CARDIOVASCULAR* yes no
Sinusitis Vertigo Normal PMI in MCL, no thrill
Other: Other: RRR, no MRGs
Respiratory no yes Endocrine no yes BPs equal on R and L (if indicated)
Short of breath Excess thirst
Normal carotid pulses, no bruits
Cough Polyuria
*HPI Elements: Location, Quality, Timing, Severity, Duration, Context, Modifying Normal abdominal aorta pulsations
Hemoptysis Cold intolerance
Factors, Associated Signs and Symptoms Normal femoral pulses
Wheezing Heat intolerance
Past Medical, Family and Social History Normal pedal pulses
Pleurisy Goiter

e
Other: Other: PMH No lower extremity edema
Cardiovascular no yes Psychiatric no yes FH GASTROINTESTINAL* yes no
Chest pain Depression Abdomen soft, with no masses
PND Anxiety SH
No hepatosplenomegaly
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
Guiaic negative (if indicated)
MUSCULOSKELETAL
Back shows no kyphosis or scoliosis
Normal gait and station
yes no
m
Normal muscle strength and tone
Nausea Easy bruising
EXTREMITIES yes no
Vomiting Bleeding diathesis
No digital cyanosis or clubbing
Diarrhea Blood clots
SKIN yes no
Hematemesis Swollen glands
Melena Lymphedema No xanthomas or stasis dermatitis
NEURO/PSYCHIATRIC* yes no
Sa

Other: Other:
Genitourinary no yes Allrgic/Immun no yes Appropriate affect
Hematuria Allergic rhinitis A&OX3
Dysuria Hay fever Data Points
Problem Focused Exam: 1 - 5 bullets
Hesitancy Asthma Expanded Problem Focused Exam : 6 - 11 bullets
Review Review and/ Review and/or order Discuss Review any Order
Summarize
Incontinence Positive PPD and/or or order X- medical test (PFTs, test with image, tracing, old Detailed Exam: 12 bullets
old records
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