E&M Score Sheet: Ears, Nose and Throat

1 SPECIALTY EXAM: EARS, nose AND THROATP erformed and DocumentedLevel of ExamOne to five bulletsSix to eleven bulletsTwelve or more bulletsAt least one bullet in each box with an unshaded borderAND every bullet in each box with a shaded FocusedExpanded Problem FocusedDetailedComprehensive(Circle the bullets that are documented.)System/BodyAreaElements of ExaminationHIC#DATE OF SERVICE(Enter the number of circled bullets in the boxes below. Then circle the appropriate level of care.)Answer the following two questions. If bothanswers are "yes," the appropriate level ofexam is at least one bullet documented in eachunshaded box?

2 YesNoWas each bullet in each shaded boxdocumented?YesNo EXAMOne to FiveBulletsSix to ElevenBulletsTwelve ormore BulletsProblem FocusedExpanded ProblemFocusedDetailedComprehensive1b102 27 11/97 Note:Review of Chest (Breasts), Gastrointestinal (Abdomen), Genitourinary, Musculoskeletal, Extremities, and Skin are notconsidered integral parts of this specialty to data section (table below) in order to quantify. After reviewing the medical record documentation, identifythe level of examination. Circle the level of examination within the appropriate grid in Section 5 (Page 3).

3 Eyes1aTest ocular motility including primary gaze alignmentRespiratoryInspection of chest including symmetry, expansion and/or assessment ofrespiratory effort ( , intercostal retractions, use of accessory muscles,diaphragmatic movement)Auscultation of lungs ( , breath sounds, adventitious sounds, rubs)CardiovascularAuscultation of heart with notation of abnormal sounds and murmursExamination of peripheral vascular system by observation ( , swelling,varicosities) and palpation ( , pulses, temperature, edema, tenderness)LymphaticPalpation of lymph nodes in neck, axillae, groin and/or other locationNeurological/PsychiatricTest cranial nerves with notation of any deficitszzzzzzzBrief assessment of mental status including.

4 Orientation to time, place and personMood and affect ( , depression, anxiety, agitation)zzInspection of head and face ( , overall appearance, scars, lesions and masses)Palpation and/or percussion of face with notation of presence or absence of sinustendernessExamination of salivary glandsAssessment of facial strengthExamination of neck ( , masses, overall appearance, symmetry, tracheal position,crepitus)Examination of thyroid ( , enlargement, tenderness, mass)Head and FacezzzzzzzzzzOtoscopic examination of external auditory canals and tympanic membranesincluding pneumo-otoscopy with notation of mobility of membranesAssessment of hearing with tuning forks and clinical speech reception thresholds( , whispered voice, finger rub)External inspection of ears and nose ( , overall appearance, scars, lesions andmasses)Inspection of nasal mucosa, septum, and turbinatesInspection of lips, teeth and gumsExamination of oropharynx.

5 Oral mucosa, hard and soft palates, tongue, tonsils andposterior pharynx ( , asymmetry, lesions, hydration of mucosal surfaces)Inspection of pharyngeal walls and pyriform sinuses ( , pooling of saliva,asymmetry, lesions)Examination by mirror of larynx including the condition of the epiglottis, false vocalcords, true vocal cords and mobility of larynx (Use of mirror not required in children)Examination by mirror of nasopharynx including appearance of the mucosa,adenoids, posterior choanae and eustachian tubes (Use of mirror not required inchildren)Ears, nose , Mouth andThroatzzConstitutionalNeckzzzzzzEleme nts of ExaminationSystem/Body AreaMeasurement of any three of the following seven vital signs.

6 1) sitting or standingblood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration,5) temperature, 6) height, 7) weight (May be measured and recorded by ancillarystaff)General appearance of patient ( , development, nutrition, body habitus,deformities, attention to grooming)Assessment of ability to communicate ( , use of sign language or othercommunication aids) and quality of voiceNOTE:For the descriptions of the elements of examination containing the words "and", "and/or", only one (1) of thoseelements must be documented.