Cardiovascular Examination

System/Body Area	Elements of Examination
Constitutional	Measurement of any three of the following seven vital signs:  1) sitting or standing blood pressure; 2) supine blood pressure; 3) pulse rate and regularity; 4) respiration; 5) temperature; 6) height; 7) weight (May be measured and recorded by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
Head and face
Eyes	Inspection of conjunctivae and lids (eg, xanthelasma)
Ears, Nose,  Mouth and Throat	Inspection of teeth, gums and palate Inspection of oral mucosa with notation of presence of pallor or cyanosis
Neck	Examination of jugular veins (eg, distention; a, v or cannon a waves) Examination of thyroid (eg, enlargement, tenderness, mass)
Respiratory	Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
Cardiovascular	Palpation of heart (eg, location, size and forcefulness of the point of maximal impact; thrills; lifts; palpable S3 or S4) Auscultation of heart including sounds, abnormal sounds and murmurs Measurement of blood pressure in two or more extremities when indicated (eg, aortic dissection, coarctation)      Examination of: Carotid arteries (eg, waveform, pulse amplitude, bruits, apical-carotid delay) Abdominal aorta (eg, size, bruits) Femoral arteries (eg, pulse amplitude, bruits) Pedal pulses (eg, pulse amplitude) Extremities for peripheral edema and/or varicosities
Chest (Breasts)
Gastrointestinal (Abdomen)	Examination of abdomen with notation of presence of mass or tenderness Examination of liver and spleen Obtain stool sample for occult blood from patients being considered for thrombolytic or anticoagulant therapy
Genitourinary (Abdomen)
Lymphatic
Musculoskeletal	Examination of the back with notation of kyphosis or scoliosis Examination of gait with notation of ability to undergo exercise testing and/or participation in exercise programs Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements.
Extremities	Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, Osler's nodes)
Skin	Inspection and/or palpation of skin and subcutaneous tissue (eg, stasis dermatitis, ulcers, scars, xanthomas)
Neurological/ Psychiatric	Brief assessment of mental status including Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation)

Content and Documentation Requirements

Level of Exam	Perform and Document:
Problem Focused	One to five elements identified by a bullet
Expanded Problem Focused	At least six elements identified by a bullet
Detailed	At least twelve elements identified by a bullet
Comprehensive	Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border.

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Ear, Nose and Throat Examination

System/Body Area	Elements of Examination
Constitutional	Measurement of any three of the following seven vital signs:  1) sitting or standing blood pressure; 2) supine blood pressure; 3) pulse rate and regularity; 4) respiration; 5) temperature; 6) height; 7) weight (May be measured by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming) Assessment of ability to communicate (eg, use of sign language or other communication aids) and quality of voice
Head and Face	Inspection of head and face (eg, overall appearance, scars, lesions and masses) Palpation and/or percussion of face with notation of presence or absence of sinus tenderness Examination of salivary glands Assessment of facial strength
Eyes	Test ocular motility including primary gaze alignment
Ears, Nose, Mouth and Throat	Otoscopic examination of external auditory canals and tympanic membranes including pneumo-otoscopy with notation of mobility of membranes Assessment of hearing with tuning forks and clinical speech reception thresholds (eg, whispered voice, finger rub) External inspection of ears and nose (eg, overall appearance, scars, lesions and masses) Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums Examination of oropharynx:  Oral mucosa, hard and soft palates, tongue, tonsils and posterior pharynx (eg, asymmetry, lesions, hydration of mucosal surfaces) Inspection of pharyngeal walls and pyriform sinuses (eg, pooling of saliva, asymmetry, lesions) Examination by mirror of larynx including the condition of the epiglottis, false vocal cords, true vocal cords and mobility of larynx (Use of mirror not required in children) Examination by mirror of nasopharynx including appearance of the mucosa, adenoids, posterior choanae and eustachian tubes (Use of mirror not required in children)
Neck	Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass)
Respiratory	Inspection of chest including symmetry, expansion and/or assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
Cardiovascular	Auscultation of heart with notation of abnormal sounds and murmurs Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)
Chest (Breasts)
Gastrointestinal (Abdomen)
Genitourinary
Lymphatic	Palpation of lymph nodes in neck, axillae, groin and/or other location
Musculoskeletal
Extremities
Skin
Neurological/ Psychiatric	Test cranial nerves with notation of any deficits      Brief assessments of mental status including Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation)

Content and Documentation Requirements

Level of Exam	Perform and Document:
Problem Focused	One to five elements identified by a bullet
Expanded Problem Focused	At least six elements identified by a bullet
Detailed	At least twelve elements identified by a bullet
Comprehensive	Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border.

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Eye Examination

System/Body Area	Elements of Examination
Constitutional
Head and Face
Eyes	Test visual acuity (Does not included determination of refractive error) Gross visual field testing by confrontation Test ocular motility including primary gaze alignment Inspection of bulbar and palpebral conjunctivae Examination of ocula adnexae including lids (eg, ptosis or lagopthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes Examination of pupils and irises including shape, direct and consensual reaction (afferent pupil), size, (eg, anisocoria) and morphology Slit lamp examination of the corneas including epithelium, stroma, endothelium, and tear film Slit lamp examination of the anterior chambers including depth, cells and flare Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus Measurement of intraocular pressures (except in children and patients with trauma or infectious disease      Ophthalmoscopic examination through dilated pupils (unless contraindicated) of Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, tumor elevation) and nerve fiber layer Posterior segments including retina and vessels (eg, exudates and hemorrhages)
Ears, Nose, Mouth and Throat
Neck
Respiratory
Cardiovascular
Chest (Breasts)
Gastrointestinal (Abdomen)
Genitourinary
Lymphatic
Musculoskeletal
Extremities
Skin
Neurological/ Psychiatric	Brief assessment of mental status including Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation

Content and Documentation Requirements

Level of Exam	Perform and Document:
Problem Focused	One to five elements identified by a bullet
Expanded Problem Focused	At least six elements identified by a bullet
Detailed	At least nine elements documented by a bullet
Comprehensive	Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border.

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Genitourinary Examination

System/Body Area	Elements of Examination
Constitutional	Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be recorded by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
Head and Face
Eyes
Ears, Nose, Mouth and Throat
Neck	Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass)
Respiratory	Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Auscultation of lungs (eg, pulses, temperature, edema, tenderness)
Cardiovascular	Auscultation of heart with notation of abnormal sounds and murmurs Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)
Chest (Breasts)	[See genitourinary (female)]
Gastrointestinal (Abdomen)	Examination of abdomen with notation of presence of masses or tenderness Examination for presence or absence of hernia Examination of liver and spleen Obtain stool samples of occult blood test when indicated
Genitourinary	MALE: Inspection of anus and perineum      Examination (with or without specimen collection for smears and cultures) of genitalia including: Scrotum (eg, lesions, cysts, rashes) Epididymides (eg, size, symmetry, masses) Testes (eg, size, symmetry, masses) Urethral meatus (eg, size, location, lesions, discharge) Penis (eg, lesions, presence or absence of foreskin, foreskin retractibility, plaque, masses, scarring, deformities)      Digital rectal examination including: Prostate gland (eg, size, symmetry, nodularity, tenderness) Seminal vesicles (eg, symmetry, tenderness, masses, enlargement) Sphincter tone, presence of hemorrhoids, rectal masses      FEMALE:      Includes at least seven of the following eleven elements identified by bullets: Inspection and palpation of breasts (eg, masses or lumps, tenderness, symmetry, nipple discharge) Digital rectal examination including sphincter tone, presence of hemorrhoids, rectal masses      Pelvic examination (with or without specimen collection for smears and cultures) including: External genitalia (eg, general appearance, hair distribution, lesions) Urethral meatus (eg, size, location, lesions, prolapse) Bladder (eg, fullness, masses, tenderness) Vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) Cervix (eg, general appearance, lesions, discharge) Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity) Anus and perineum
Lymphatic	Palpation of lymph nodes in neck, axillae, groin and/or other location
Musculoskeletal
Extremities
Skin	Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)
Neurological/ Psychiatric	Brief assessment of mental status including Orientation (eg, time, place and person) and Mood and affect (eg, depression, anxiety, agitation)

Content and Documentation Requirements

Level of Exam	Perform and Document
Problem Focused	One to five elements identified by a bullet
Expanded Problem Focused	At least six elements identified by a bullet
Detailed	At least twelve elements identified by a bullet
Comprehensive	Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border.

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Hematologic/Lymphatic/Immunologic Examination

System/Body Area	Elements of Examination
Constitutional	Measurement of any three of the following seven vital signs:  1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
Head and Face	Palpation and/or percussion of face with notation of presence or absence of sinus tenderness
Eyes	Inspection of conjunctivae and lids
Ears, Nose Mouth and Throat	Otoscopic examination of external auditory canals and tympanic membranes Inspection of nasal mucosa, septum and turbinates Inspection of teeth and gums Examination of oropharynx (eg, oral mucosa, hard and soft palates, tongue, tonsils, posterior pharynx)
Neck	Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass)
Respiratory	Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
Cardiovascular	Auscultation of heart with notation of abnormal sounds and murmurs Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema , tenderness)
Chest (Breasts)
Gastrointestinal (Abdomen)	Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen
Genitourinary
Lymphatic	Palpation of lymph nodes in neck, axillae, groin, and/or other location
Musculoskeletal
Extremities	Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)
Skin	Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers, ecchymoses, bruises)
Neurological/ Psychiatric	Brief assessment of mental status including Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation)

Content and Documentation Requirements

Level of Exam	Perform and Document
Problem Focused	One to five elements identified by a bullet
Expanded Problem Focused	At least six elements identified by a bullet
Detailed	At least twelve identified by a bullet
Comprehensive	Perform all elements identified by a bullet;  document every element in each box with a shaded border and at least one element in each box with an unshaded border.

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Musculoskeletal Examination

System/Body Area	Elements of Examination
Constitutional	Measurement of any three of the following seven vital signs:  1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
Head and Face
Eyes
Ears, Nose Mouth and Throat
Neck
Respiratory
Cardiovascular	Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)
Chest (Breasts)
Gastrointestinal (Abdomen)
Genitourinary
Lymphatic	Palpation of lymph nodes in neck, axillae, groin and/or other location
Musculoskeletal	Examination of gait and station      Examination of joint(s), bone(s), and muscle(s)/tendon(s) of four of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity.  The examination of a given area includes: Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions Assessment of range of motion with notation of any pain (eg, straight leg raising), crepitation or contracture Assessment of stability with notation of any dislocation (luxation), subluxation or laxity Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements. NOTE:  For the comprehensive level of examination, all four of the elements identified by a bullet must be performed and documented for each of four anatomic areas.  For the three lower levels of examination, each element is counted separately for each body area.  For example, assessing range of motion in two extremities constitutes two elements.
Extremities	[See musculoskeletal and skin]
Skin	Inspection and/or palpation of skin and subcutaneous tissue (eg, scars, rashes, lesions, cafe-au-lait spots, ulcers) in for of the following six areas: 1) head and neck; 2) trunk; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. NOTE:  For the comprehensive level, the examination of all four anatomic areas must be performed and documented.  For the three lower levels of examination, each body area is counted separately.  For example, inspection and/or palpation of the skin and subcutaneous tissue of two extremities constitutes two elements.
Neurological/ Psychiatric	Test coordination (eg, finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children) Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes (eg, Babinski) Examination of sensation (eg, by touch, pin, vibration, proprioception)      Brief assessment of mental status including Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation)

Content and Documentation Requirements

Level of Exam	Perform and Document
Problem Focused	One to five elements identified by a bullet
Expanded Problem Focused	At least six elements identified by a bullet
Detailed	At least twelve elements identified by a bullet
Comprehensive	Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border.

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Neurological Examination

System/Body Area	Elements of Examination
Constitutional	Measurement of any three of the following seven vital signs:  1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
Head and Face
Eyes	Ophthalmoscopic examination of optic discs (eg, sizes, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)
Ears, Nose Mouth and Throat
Neck
Respiratory
Cardiovascular	Examination of carotid arteries (eg, pulse amplitude, bruits) Auscultation of heart with notation of abnormal sounds and murmurs Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)
Chest (Breasts)
Gastrointestinal (Abdomen)
Genitourinary
Lymphatic
Musculoskeletal	Examination of gait and station      Assessment of motor function including: Muscle strength in upper and lower extremities Muscle tone in upper and lower extremities (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements (eg, fasciculation, tardive dyskinesia)
Extremities	[See musculoskeletal]
Neurological	Evaluation of higher integrative functions including: Orientation to time, place and person Recent and remote memory Attention span and concentration Language (eg, naming objects, repeating phrases, spontaneous speech)      Test the following cranial nerves 2nd cranial nerve (eg, visual acuity, visual fields, fundi) 3rd, 4th, and 6th cranial nerves (eg, pupils and eye movements) 5th cranial nerve (eg, facial sensation, corneal reflexes) 7th cranial nerve (eg, facial symmetry, strength) 8th cranial nerve (eg, hearing with tuning fork, whispered voice and/or finger rub) 9th cranial nerve (eg, spontaneous and reflex palate movement) 11th cranial nerve (eg, shoulder shrug strength) 12 the cranial nerve (eg, tongue protrusion) Examination of sensation (eg, by touch, pin, vibration, proprioception) Examination of deep tendon reflexes in upper and lower extremities with notation of pathological reflexes (eg, Babinski) Test coordination (eg, finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)
Psychiatric

Content and Documentation Requirements

Level of Exam	Perform and Document
Problem Focused	One to five elements identified by a bullet
Expanded Problem Focused	At least six elements identified by a bullet
Detailed	At least twelve elements identified by a bullet
Comprehensive	Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border.

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Psychiatric Examination

System/Body Area	Elements of Examination
Constitutional	Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
Head and Face
Eyes
Ears, Nose Mouth and Throat
Neck
Respiratory
Cardiovascular
Chest (Breasts)
Gastrointestinal (Abdomen)
Genitourinary
Lymphatic
Musculoskeletal	Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements Examination of gait and station
Extremities
Skin
Neurological
Psychiatric	Description of speech including:  rate; volume; articulation; coherence; and spontaneity with notation of abnormalities (eg, perserveration, paucity of language) Description of thought processes including: rate of thoughts, content of thoughts (eg, logical vs. illogical, tangential); abstract reasoning; and computation Description of associations (eg, loose, tangential, circumstantial, intact) Description of abnormal or psychotic thoughts including:  hallucinations; delusions; preoccupation with violence; homicidal or suicidal ideation; and obsessions. Description of the patient's judgment (eg, concerning everyday activities and social situations) and insight (eg, concerning psychiatric condition)      Complete mental status examination including Orientation to time, place and person Recent and remote memory Attention span and concentration Language (eg, naming objects, repeating phrases) Fund of knowledge (eg, awareness of current events, past history, vocabulary) Mood and affect (eg, depression, anxiety, agitation, hypomania, lability)

Content and Documentation Requirements

Level of Exam	Perform and Document
Problem Focused	One to five elements identified by a bullet
Expanded Problem Focused	At least six elements identified by a bullet
Detailed	At least nine elements identified by a bullet
Comprehensive	Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border.

 

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