CONTENT AND DOCUMENTATION REQUIREMENTS

General Multi-System Examination

Elements of Examination
System/Body
Area

Constitutional 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, Including Inspection of head and face (eg, overall appearance, scars, lesions and masses)
face
Palpation and/or percussion of face with notation of presence or absence of sinus
tenderness
Examination of salivary glands Assessment of facial strength

Eyes 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)

Ears, Otoscopic examination of external auditory canals and tympanic membranes

Nose, including pneumo-otoscopy with notation of mobility of membranes Assessment of
Mouth and hearing with tuning forks and clinical speech reception thresholds (eg, whispered
Throat 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 Examination of neck (eg, masses, overall appearance, symmetry, tracheal position,
crepitus)
Examination of thyroid (eg, enlargement, tenderness, mass)

Respiratory 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 Palpation of heart (eg, location, size and forcefulness of the point of maximal impact;
thrills; lifts; palpable S3 or S4)

Auscultation of heart with notation of abnormal sounds and murmurs

Measurement of blood pressure in two or more extremities when indicated (eg, aortic
dissection, coarctation)

Examination of:

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

Chest (Breasts) Inspection of breasts (eg, symmetry, nipple discharge)

Palpation of breasts and axillae (eg, masses or lumps, tenderness)

Gastrointestin Examination of abdomen with notation of presence of masses or tenderness

al (Abdomen)
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:

• Inspection of anus and perineum

Examination (with or without specimen collection for smears and cultures) of

genitalia including:

• Scrotum (eg, lesions, cysts, rashes)

• Epididymides (eg, size, symmetry, masses)

• Testes (eg, size, symmetry, masses)

• Urethral meatus (eg, size, location, lesions, discharge)

• Penis (eg, lesions, presence or absence of foreskin, foreskin

retractability, plaque, masses, scarring, deformities)

Digital rectal examination including:

• Prostate gland (eg, size, symmetry, nodularity, tenderness)

• Seminal vesicles (eg, symmetry, tenderness, masses, enlargement)

Sphincter tone, presence of hemorrhoids, rectal masses

 FEMALE:

• Inspection and palpation of breasts (eg, masses or lumps, tenderness, symmetry, nipple
discharge)
• Digital rectal examination including sphincter tone, presence of hemorrhoids, rectal
masses

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

• External genitalia (eg, general appearance, hair distribution, lesions)

Urethral meatus (eg, size, location, lesions, prolapse)

• Urethra (eg, masses, tenderness, scarring)

• Bladder (eg, fullness, masses, tenderness)

• Vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support,
cystocele, rectocele)

• Cervix (eg, general appearance, lesions, discharge)

• Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support)

• Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)

Anus and perineum

Musculoskeletal Examination of gait and station

Inspection and/or palpation of digits and nails (eg, 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 (eg, flaccid, cog wheel, spastic) with notation
of any atrophy or abnormal movements
 IPalpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area
Skin (when indicated) and extremities

Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions,
ulcers, susceptibility to and presence of photo damage) in eight of the following ten
areas:
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 lower 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
TEvaluation of higher integrative functions including:
Neurologic

• 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)
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 (eg, depression, anxiety, agitation)

Lymphatic
Palpation of lymph nodes in two or more areas: Neck

Axillae

Groin

Other