Content and Documentation Requirements

Level of Exam : Problem Focused

Perform and Document:  One to five elements identified by a bullet.

Level of Exam : Expanded Problem Focused

Perform and Document:At least six elements identified by a bullet.

Level of Exam : Detailed

Perform and Document:At least two elements identified by a bullet from each of six areas/systems OR at least twelve elements identified by a bullet in two or more areas/systems

Level of Exam : Comprehensive

Perform and Document:Perform all elements identified by a bullet in at least nine organ systems or body areas and document at least two elements identified by a bullet from each of nine areas/systems.

Cardiovascular Examination 

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)  

Head and Face

System/Body Area: Eyes 

Elements of Examination:Inspection of conjunctivae and lids (eg, xanthelasma) 

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

Elements of Examination:

• Inspection of teeth, gums and palate 
• Inspection of oral mucosa with notation of presence of pallor or cyanosis

System/Body Area: Neck

Elements of Examination:

• Examination of jugular veins (eg, distension; a, v or cannon a waves)
• Examination of thyroid (eg, enlargement, tenderness, mass) 

System/Body Area: Respiratory

Elements of Examination:

• Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) 
• Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs) 

System/Body Area: Cardiovascular

Elements of Examination:

• Palpation of heart (eg, location, size and forcefulness of the point of maximal impact; thrills; lifts; palpable S3 or S4) 
• Auscultation of heart including sounds, abnormal sounds and murmurs 
• Measurement of blood pressure in two or more extremities when indicated (eg, aortic dissection, coarctation)

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