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System/Body Area
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Elements of Examination
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Constitutional
*All elements must be documented. |
- 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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| Eyes |
- Inspection of conjunctivae and lids
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Ears, Nose, Mouth and Throat
*All elements must be documented. |
- Inspection of lips, teeth and gums
- Examination of oropharynx (e.g., oral mucosa, hard and soft palates, tongue, tonsils, posterior pharynx)
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| Neck |
- Examination of thyroid (e.g., enlargement, tenderness, mass)
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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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| Gastrointestinal (Abdomen) |
- Examination of liver and spleen
- Examination of anus for condyloma and other lesions
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| Lymphatic |
- Palpation of lymph nodes in neck, axillae, groin and/or other location
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| Extremities |
- Inspection and palpation of digits and nails (e.g., clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)
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Skin
*All elements must be documented. |
- Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities
- Inspection and/or palpation of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following 10 areas:
- Head including face
- 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 constitute two elements.
- Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis
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Neurological/
Psychiatric |
Brief assessment of mental status including:
- Orientation to time, place and person
- Mood and affect (e.g., depression, anxiety, agitation)
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