'Click to return to E/M University Home page, EM Coding Education
Detailed Physical Exam
 

 


The Detailed Physical Exam is the second highest level of physical exam. We recommend using the 1997 physical exam rules.

1997 Detailed Exam requires at least 12 bullets from any organ systems.

At least 12 bullets from any organ systems

Example

Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Neck: FROM, supple
Lungs: Clear to auscultation
CV: RRR, no MRGs; normal carotid upstroke and amplitude without bruits
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or digital cyanosis
Skin: no rash, lesions or ulcers
Psych: Alert and oriented to person, place and time

(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for examination of neck)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
(1 bullet for assessment of carotid arteries)
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)
(1 bullet for examination of extremities for edema)
(1 bullet for examination and/or palpation of digits and nails)
(1 bullet for inspection of skin and subcutaneous tissue)
(1 bullet for brief assessment of mental status—orientation)

Total bullets = 12





Home   |   Contact Us   |   Privacy Policy
Copyright © 2003 -  EM University. Web Design: Abacus Web Services
 
Click to return to E/M University Home page, EM Coding Education