CONTENT AND DOCUMENTATION REQUIREMENTS

System/Body Area :  Constitutional

Elements of Examination :  

• 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) 

System/Body Area :  Eyes

Elements of Examination :  

• Inspection of conjunctivae and lids 
• Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry) 
• Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)

System/Body Area :Ears, Nose, Mouth and Throat 

Elements of Examination :  

• External inspection of ears and nose (eg, overall appearance, scars, lesions, masses) 
• Otoscopic examination of external auditory canals and tympanic membranes 
• Assessment of hearing (eg, whispered voice, finger rub, tuning fork) 
• Inspection of nasal mucosa, septum and turbinates 
• Inspection of lips, teeth and gums 
• Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx 

System/Body Area :Neck

Elements of Examination :  

• Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass)