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System/Body Area
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Elements of Examination
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Constitutional
*All elements must be documented.
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- Measurement of any three of the following seven vital signs:
- Sitting or standing blood pressure
- Supine blood pressure
- Pulse rate and regularity
- Respiration
- Temperature
- Height
- Weight (may be measured and recorded by ancillary staff)
- General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)
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| Cardiovascular |
- Examination of peripheral vascular system by observation (e.g., swelling, varicosities) and palpation (e.g., pulses, temperature, edema, tenderness)
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| Lymphatic |
- Palpation of lymph nodes in neck, axillae, groin and/or other location
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Musculoskeletal
*All elements must be documented. |
- Examination of gait and station
Examination of joint(s), bone(s) and muscle(s)/ tendon(s) of four of the following six areas:
- Head and neck
- Spine, ribs and pelvis
- Right upper extremity
- Left upper extremity
- Right lower extremity
- Left lower extremity
The examination of a given area includes:
- Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
- Assessment of range of motion with notation of any pain (e.g., straight leg raising), 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
Note: For the comprehensive level of examination, all four of the elements identified by a bullet must be performed and documented for each of four anatomic areas. For the three lower levels of examination, each element is counted separately for each body area. For example, assessing range of motion in two extremities constitutes two elements. |
| Extremities |
[See musculoskeletal and skin] |
Skin
*All elements must be documented. |
- Inspection and/or palpation of skin and subcutaneous tissue (e.g., scars, rashes, lesions, cafe-au-lait spots, ulcers) in four of the following six areas:
- Head and neck
- Trunk
- Right upper extremity
- Left upper extremit
- Right lower extremity
- Left lower extremity
Note: For the comprehensive level, the examination of all four 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 two extremities constitute two elements. |
Neurological/
Psychiatric
*All elements must be documented. |
- Test coordination (e.g., finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children
- Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes (e.g., Babinski)
- Examination of sensation (e.g., by touch, pin, vibration, proprioception)
Brief assessment of mental status including:
- Orientation to time, place and person
- Mood and affect (e.g., depression, anxiety, agitation)
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