Constitutional

check all 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)

Respiratory

check all Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

check all 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

Gastrointestinal (Abdomen)

check all Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen Obtain stool sample for occult blood from patients who are being considered for thrombolytic or anticoagulant therapy

Neurological/Psychiatric

check all

Brief assessment of mental status including

Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation)

Constitutional

check all 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) Assessment of ability to communicate (eg, use of sign language or other communication aids) and quality of voice

Head and Face

check all 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

Ears, Nose, Mouth and Throat

check all Otoscopic examination of external auditory canals and tympanic membranes including Mouth 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

check all Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass)

Eyes

check all Test visual acuity (Does not include 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 ocular adnexae including lids (eg, ptosis or lagophthalmos), 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)

Constitutional

check all 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)

Gastrointenstinal (Abdomen)

check all 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 sample for occult blood test when indicated

Genitourinary

check all Select Male or Female: Male Female

Constitutional

check all 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)

Ears, Nose, Mouth and Throat

check all 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)

Respiratory

check all Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

check all 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)

Gastrointenstinal (Abdomen)

check all Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen

Constitutional

check all 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)

Musculoskeletal

check all 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:

Head and Neck

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

Spine, ribs and pelvis

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

Right upper extremity

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

Left upper extremity

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

Right lower extremity

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

Left lower extremity

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

Extremities

[See musculoskeletal and skin]

Skin

check all

Inspection and/or palpation of skin and subcutaneous tissue (eg, scars, rashes, lesions, cafeau-lait spots, ulcers) in four of the following six areas:

Head and neck Trunk Right upper extremity Left upper extremity Right lower extremity Left lower extremity

Neurological/Psychiatric

check all 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)

Constitutional

check all 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)

Eyes

check all Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)

Musculoskeletal

check all 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)

Neurological

check all

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) Fund of knowledge (eg, awareness of current events, past history, vocabulary)

Test the following cranial nerves:

2nd cranial nerve (eg, visual acuity, visual fields, fundi) 3rd, 4th and 6th cranial nerves (eg, pupils, 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 or reflex palate movement) 11th cranial nerve (eg, shoulder shrug strength) 12th 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)

Constitutional

check all 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)

Psychiatric

check all Description of speech including: rate; volume; articulation; coherence; and spontaneity with notation of abnormalities (eg, perseveration, 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)

Constitutional

check all 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)

Ears, Nose, Mouth and Throat

check all Inspection of nasal mucosa, septum and turbinates Inspection of teeth and gums Examination of oropharynx (eg, oral mucosa, hard and soft palate, tongue, tonsils and posterior pharynx)

Neck

check all Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass) Examination of jugular veins (eg, distention, a, v or cannon a waves)

Respiratory

check all Inspection of chest with notation of symmetry and expansion Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Percussion of chest (eg, dullness, flatness, hyperresonance) Palpation of chest (eg, tactile fremitus) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

check all Auscultation of heart with notation of abnormal sounds and murmurs Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (pulses, temperature, edema, tenderness)

Gastrointenstinal (Abdomen)

check all Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen

Constitutional

check all 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)

Ears, Nose, Mouth and Throat

check all Inspection of teeth and gums Examination of oropharynx (eg, oral mucosa, hard and soft palates, tongue, tonsils, posterior pharynx)

Skin

check all Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities

Head, including the face and Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks Back Right upper extremity Left upper extremity Right lower extremity Left upper extremity

NOTE: For the comprehensive level, the examination of at least eight 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 the right upper extremity and the left upper extremity constitutes two elements.

Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis