The extent of examination involving not only the chief complaint extended history of present illness

Constitutional

• Measurements 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 the patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)

Eyes

• Inspection of conjunctivae and lids
• Examination of pupils and irises (e.g., reaction to light and accommodation, size and symmetry)
• Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages)

Ear, Nose, Mouth, and Throat

• External inspection of ear and nose (e.g., overall appearance, scars, lesions, masses)
• Otoscopic examination of external auditory canals and tympanic membranes
• Assessment of hearing (e.g., whispered voice, finger rub, tuning fork)
• Inspection of nasal mucosa, septum and turbinates
• Inspection of lips, teeth and gums
• Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx

Neck

• Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
• Examination of thyroid (e.g., enlargement, tenderness, mass)

Respiratory

• Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
• Percussion of chest (e.g., dullness, flatness, hyperresonance)
• Palpation of chest (e.g., tactile fremitus)
• Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)

Cardiovascular

• Palpation of heart (e.g., location, size, thrills)
• Auscultation of heart with notation of abnormal sounds and murmurs

Examination of:

• carotid arteries (e.g., pulse, amplitude, bruits)
• abdominal aorta (e.g., size, bruits)
• femoral arteries (e.g., pulse, amplitude, bruits)
• pedal pulses (e.g., pulse, amplitude)
• extremities for edema and/or varicosities

Chest (Breasts)

• Inspection of breasts (e.g., symmetry, nipple discharge)
• Palpation of breasts and axillae (e.g., masses or lumps, tenderness)

Gastrointestinal (Abdomen)

• Examination of abdomen with notation of presence of masses or tenderness
• Examination of liver and spleen
• Examination for presence or absence of hernia
• Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
• Obtain stool sample for occult blood test when indicated

Genitourinary

MALE:

• Examination of the scrotal contents (e.g., hydrocele, spermatocele, tenderness of cord, testicular mass)
• Examination of the penis
• Digital rectal examination of prostate gland (e.g., size, symmetry, nodularity, tenderness)

FEMALE:

Pelvic examination (with or without specimen collection for smears and cultures), including

• Examination of external genitalia (e.g., general appearance, hair distribution, lesions) and vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
• Examination of urethra (e.g., masses, tenderness, scarring)
• Examination of bladder (e.g., fullness, masses, tenderness)
• Cervix (e.g., general appearance, lesions, discharge)
• Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)
• Adnexa/parametria (e.g., masses. tenderness, organomegaly, nodularity)

Lymphatic

Palpation of lymph nodes in two or more areas:

• Neck
• Axillae
• Groin
• Other

Musculoskeletal

• Examination of gait and station
• Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)

Examination of joints, bones and muscles of one or more 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 and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions
• Assessment of range of motion with notation of any pain, crepitation, or contracture
• Assessment of stability with notation of any dislocation (luxation), subluxation, or laxity
• Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

Skin

• Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
• Palpation of skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening)

Neurologic

• Test cranial nerves with notation of any deficits
• Examination of deep tendon reflexes with notation of pathological reflexes (e.g., Babinski)
• Examination of sensation (e.g., by touch, pin, vibration, proprioception)

Psychiatric

• Description of patient’s judgment and insight

Brief assessment of mental status including:

• orientation to time, place, and person
• recent and remote memory
• mood and affect (e.g., depression, anxiety, agitation)

Which extent of history includes documentation of chief complaint extended history of present illness?

Which type of history includes documentation of four or more elements of the history?

What type of examination involves the affected area of the illness and other systems or related organs?

When selecting a type of history the coder should review the chief complaint history of the presenting illness review of systems and past family and social history?