Review of Systems Physical Exam (Each check box = 1 bullet)
Patient: _____________________ Date: __________
Constitutional no yes Musculoskeletal no yes CONSTITUTIONAL Abnormal
Weight loss Arthralgias New Office Patient Record three vital signs yes no Findings
Fevers Myalgias 3 out of 3 Key Components Required
Chills Muscle weakness E/M Hx Exam MDM Time
99201 PF PF SF 10 Conversant/NAD
Night sweats Joint swelling
99202 EPF EPF SF 20 EYES yes no
Fatigue NSAID use
99203 Det Det Low 30 Pink conjunctivae; no ptosis
Other: Other:
99204 Comp Comp Mod 45 PERRLA
Eyes no yes Skin no yes
99205 Comp Comp High 60
Blurry vision Rash Fundi clear, no AV nicking
Eye pain Pruritis Chief Complaint: ENMT yes no
Discharge Sores HPI Brief: 1 - 3 HPI elements* Extended: 4 HPI elements* or status of 3 problems Nose and ears appear normal
Dry eyes Nail changes Good dentition
Decreased vision Skin thickening
No pharyngeal erythema
Other: Other:
NECK yes no
Ears/Nose/
no yes Neurological no yes Non-tender, no masses
Throat
Sore throat Migraines No thryomegaly or nodules
Tinnitus Numbness RESPIRATORY yes no
Bloody nose Ataxia Normal respiratory effort
Hearing loss Tremors
Clear to auscultation
Sinusitis Vertigo
Clear to percussion
Other: Other:
CARDIOVASCULAR yes no
Respiratory no yes Endocrine no yes
Short of breath Excess thirst
No carotid bruits
Cough Polyuria RRR, no MRGs
Hemoptysis Cold intolerance
*HPI Elements: Location, Quality, Timing, Severity, Duration, Context, Modifying No peripheral edema
Factors, Associated Signs and Symptoms
Wheezing Heat intolerance GASTROINTESTINAL yes no
Past Medical, Family and Social History
Pleurisy Goiter Abdomen soft, with no masses
e
Other: Other: PMH No hepatosplenomegaly
Cardiovascular no yes Psychiatric no yes FH
No hernias
Chest pain Depression
SH Heme occult negative
PND Anxiety
MUSCULOSKELETAL yes no
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
Normal gait and station
No digital cyanosis or clubbing
SKIN
No rashes, ulcers or lesions
Normal turgor and temperature
yes no
m
Nausea Easy bruising NEUROLOGIC yes no
Vomiting Bleeding diathesis
CNs intact
Diarrhea Blood clots
No sensory deficits
Hematemesis Swollen glands
DTRs intact and symmetrical
Melena Lymphedema
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 Intact judgment and insight
Hesitancy Asthma Review Review and/ Review and/or order Discuss Review any Order
Summarize Problem Focused = 1 - 5 bullets.
Incontinence Positive PPD and/or or order X- medical test (PFTs, test with image, tracing, old Expanded Problem Focused = 6 - 11 bullets.
old records
UTIs Hives order labs rays EKG, echo, cath) MD specimen records Detailed = 12 bullets.
Other: Other: 1 1 1 1 2 1 2 Comprehensive = 2 bullets from EACH of NINE systems
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
