Review of Systems Physical Exam (Each check box = 1 bullet)

Patient: _____________________ Date: __________

Constitutional no yes Musculoskeletal no yes
New Office Patient CONSTITUTIONAL*
Weight loss Arthralgias
3 out of 3 Key Components Required Record three vital signs yes no
Abnormal
Fevers Myalgias
Chills Muscle weakness E/M Hx Exam MDM Time Findings
Night sweats Joint swelling 99201 PF PF SF 10
99202 EPF EPF SF 20 Well developed, well nourished
Fatigue NSAID use
99203 Det Det Low 30 NEUROLOGIC* yes no
Other: Other:
99204 Comp Comp Mod 45
Eyes no yes Skin no yes A&OX3
99205 Comp Comp High 60
Blurry vision Rash
Chief Complaint: Recent and remote memory intact
Eye pain Pruritis
Discharge Sores HPI Brief: 1 - 3 HPI elements* Extended: 4 HPI elements* or status of 3 problems Attentive with normal concentration
Dry eyes Nail changes Normal spontaneous speech pattern
Decreased vision Skin thickening
Age-appropriate fund of knowledge
Other: Other:
Ears/Nose/ Cranial nerve II intact
no yes Neurological no yes
Throat
Cranial nerves III, IV and VI intact
Sore throat Migraines
Tinnitus Numbness Cranial nerve V intact
Bloody nose Ataxia Cranial nerve VII intact
Hearing loss Tremors
Cranial nerve VIII intact
Sinusitis Vertigo
Other: Other: Cranial nerve IX intact
Respiratory no yes Endocrine no yes Cranial nerve XI intact
Short of breath Excess thirst
Cranial nerve XII intact
Cough Polyuria
Hemoptysis Cold intolerance
*HPI Elements: Location, Quality, Timing, Severity, Duration, Context, Modifying No sensory deficits
Factors, Associated Signs and Symptoms
Wheezing Heat intolerance DTRs intact and symmetrical
Past Medical, Family and Social History
Pleurisy Goiter
No dysdiadochokinesia or dysmetria

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Other: Other: PMH
Cardiovascular no yes Psychiatric no yes FH EYES* yes no
Chest pain Depression Normal optic discs
PND Anxiety SH
Normal posterior segments
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
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Level of History Documented
EPF: Brief HPI, 1 ROS, no PFSH
Comp: Ext HPI, 10 ROS, 3/3 PFSH
Data Reviewed
CARDIOVASCULAR
Normal carotid pulses bilaterally

Heart: RRR with no MRGs

yes no
m
No peripheral edema, pulses intact
Nausea Easy bruising
MUSCULOSKELETAL* yes no
Vomiting Bleeding diathesis
Diarrhea Blood clots Normal gait and station
Hematemesis Swollen glands Normal muscle strength
Melena Lymphedema
Normal muscle tone; no atrophy
Sa

Other: Other:
Genitourinary no yes Allrgic/Immun no yes No abnormal movements
Hematuria Allergic rhinitis
Dysuria Hay fever Data Points Problem Focused Exam: 1 - 5 bullets
Hesitancy Asthma Expanded Problem Focused Exam : 6 - 11 bullets
Review Review and/ Review and/or order Discuss Review any Order
Summarize Detailed Exam: 12 bullets
Incontinence Positive PPD and/or or order X- medical test (PFTs, test with image, tracing, old
order labs rays EKG, echo, cath) MD specimen records
old records Comprehensive Exam: All bullets from starred systems plus
UTIs Hives one bullet from EVERY other system
Other: Other: 1 1 1 1 2 1 2

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