Clinical Documentation Improvement Series 19. Evaluation and Management Documentation 4. Organ Systems of the Physical Exam

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Organ Systems of the Physical Exam

There are 13 organ systems from where the documentation of the physical exam can be constructed. Each of the organ systems can contribute with bullets for individual findings of the exam.

1. Constitutional. Here, 3 vital signs will count as one bullet. The general appearance can count as another one.

2. Eyes. The inspection of the eyes can be equivalent to one bullet, the exam of the pupils can count as another one

3. Ears, Nose, Mouth and Throat. The external inspection can count as one bullet and the inspection of the oropharynx as another one

4. Neck. The external appearance of the neck is one bullet , another one may be the evaluation of the thyroid gland.

5. Respiratory. Auscultation, inspection (respiratory effort), percussion and palpation can be individual bullets.

6. Cardiovascular. Auscultation, inspection (edema or varicosities), percussion and palpation can be individual bullets.

7. Gastrointestinal. Auscultation, inspection, percussion and palpation can be individual bullets. In addition, the evaluation of liver, spleen or rectum can count as individual bullets.

8. Lymphatic. The evaluation of the different lymph node groups can give you a bullet each

9. Skin. Inspection and palpation may represent a bullet each.

10. Psychiatric. Each aspect of the psychiatric exam can be a bullet. Aspects include: judgment, orientation, memory, mood, etc)

11. Genitourinary. The inspection and palpation of the genitalia can provide the necessary bullets

12. Musculoskeletal. Inspection and functional range evaluation can count as bullets

13. Neurological. Each aspect of the neurological exam can be considered a bullet. Aspects include sensory, motor, reflexes, etc)

Bibliography

Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Learning Network. "Evaluation and Management Services." Accessed April 1, 2020. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Marco A. Ramos MD, CCDS

In order to quote from this article in bibliography, Chicago style, please use the following:

Ramos, Marco. “Clinical Documentation Improvement Series 19. Evaluation and Management Documentation 4. Areas of the Past, Family and Social History”. SMO Blog (blog). April 5, 2020. https://hive.blog/hive-163521/@secondmedicalop/clinical-documentation-improvement-series-19-evaluation-and-management-documentation-4-organ-systems-of-the-physical-exam

Links to the Previous Posts in this Evaluation and Management Series

- Clinical Documentation Improvement Series 16. Evaluation and Management Documentation 1. Components of the History of Present Illness

- Clinical Documentation Improvement Series 17. Evaluation and Management Documentation 2. Individual Systems of the Review of Systems

- Clinical Documentation Improvement Series 18. Evaluation and Management Documentation 3. Areas of the Past, Family and Social History

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