DOCUMENTATION WORKSHEET - askleslie.net

1 Color Key: Items/descriptions in black represent '95 guidelines and items that did not change in '97. Items/descriptions in blue represent changes made in the '97 guidelines. Black and white duplication may alter the intent of this tool. THIS TOOL IS INTENDED TO BE USED ONLY AS A COMPANION TO THE PUBLISHED '95 AND '97 E/M DOCUMENTATION GUIDELINES (located a ). EITHER THE '95 OR '97 GUIDELINES MAY BE USED, BUT THE TWO SETS OF GUIDELINES CANNOT BE COMINGLEDP atient Name:_____ DOB:_____ DOS:_____HISTORYHPIB rief=1-3 Extended=('95) 4 or more elements or assoc.

2 Comorbidities Extended=('97) 4 or more elements orstatus of at least 3 chronic/inactive conditionsLocationQualitySeverityDuratio nTimingContext Modifying FactorsAssociated Signs/Symptoms(Where problem is located)(sharp, dull, stabbing)(scale of 1-10, etc)(how long)(how long it lasts, after meals, etc)(when walking,etc) (feel better after applying ice, etc)(swelling, redness, etc.)ROSP ertinent=1 Extended= 2-9 Complete= 10 or moreEyes Cardio Resp GI GU Endo Musculo/Skel Integumentary (skin/breast)

3 Neuro Psych Hem/LymphAllerg/ImmunPFSHP ertinent=1 Complete= 2 or more Initial visits require at least one item from all three PFSH areas Past MedicalFamily History Social History To qualify for a given level of history, all three elements in the table must be met. History level based on '95 Guidelines_____ History level based on '97 Guidelines_____Developed incorporating CMS/AMA 1995/1997 copyrighted materialsForm Date: 02/01/06 ConstitutionalPertinentChief Complaint:_____History LevelBriefBriefN/AN/AHPIENT/MouthROSPFSH Prob FocusedExp Prob FocusedN/ADetailedComprehensiveExtendedE xtendedPertinentCompleteExtendedComplete DOCUMENTATIONWORKSHEETForm Date.

4 10/03/05 BODY AREAS ('95) with '97 specific elementsORGAN SYSTEMS ('95 & '97) *Please refer to '97 Single Organ System Exam 95 97 Elements of '97 Gen. Multi-System Exam guidelines for specific bullet and numeric Head, incl faceConstitutional ('95) 3 vitals appearance requirements for each category of singleNeck and lids & irises discs organ system exam '971. Neck (masses, etc.) 2. ThyroidENT, ears & nose & TMs , turb 6. Lips, teeth, gumsCardiovasc of heart aorta arteriesChest, incl breasts or pulses for edema and/or varicosities '97 breasts breasts/axillaeRespiratory effort (Abd.)

5 , tenderness & spleen , perineum & rectum testAbdomenGU (male) ('97) contents glandGU (female) ('97) genitalia ( speci)Genitalia, groin, buttocksMusculoskeletal & station and nail (s), bone(s), muscles of at least one of these areas:a) head, neck; b) spine, ribs, pelvis; c) any one of 4 extremities, & exam to include: Back, incl spine(1)inspection &/or palpation (2)ROM (3)stability (4)muscle strength & tone of skin & subcutaneous tissue of skin and subcutaneous tissueEach nerves tendon reflexes & insight mental status: (a)orient to time, place, person (b)memory (c)moodHematologic/lymphatic/immunologic lymph nodes in 2 or more areas: a) neck b) axillae c) groin d) other '95 Guidelines.

6 Exam level based on '95 Guidelines_____ *('95)Comprehensive Exam must be 8 or more organs systems; cannot combine systems withExam level based on '97 Guidelines_____ body areas. All lower level exams can combine organ systems and body areasNumber AxPoints B Result CPoints*1x11max=21x111x22x3max=12x4 TotalTotalMinimal= < 1 Limited = 2 Multiple = 3 Extensive = 4 Minimal= < 1 Limited = 2 Multiple = 3 Extensive = 4 or more*Number values are not part of the '95 or '97 guidelines.

7 The values are added here as a means of quantifying elements of medical decision making New problem to examiner, additional workup plannedIndependent visualization of image, tracing or specimen itself (not simply review of report)Amount and/or Complexity of DataNumber of Diagnoses or Treatment OptionsNumber & category of problems/treatment options mentioned in the record (2 categories have a max allowable).Established problem to examiner; stable; improvedDiscuss test with performing/interpreting physicianDecision to obtain old records or obtain history from someone other than patientEstablished problem to examiner, worseningReview & summary of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider & DOCUMENTATION of relevant findingsNew problem to examiner, no further workup planned*Multiply A x B = CProblemReviewed DataSelf-limited or minor (stable, improving or worsening)

8 Review/order of clinical lab testsReview/order of tests in radiology section of CPTR eview/order of tests in medicine section of CPTI dentify data reviewed and circle number in points columnProb FocusedPerform and document at least 6 bulleted elements, whether in a shaded or unshaded boxLimited exam of affected body area or organ system (1)DetailedComprehensiveLimited exam of affected body area/system and other related/sympt. systems (2-7)General multi-system exam of 8 or more systems or complete exam of a single system*Perform and document at least 2 bulleted elements from at least 6 systems or body areas, or at least 12 bulleted elements from 2 or more systems or body areasPerform all bulleted elements, whether in shaded or unshaded box.

9 Document every element in each shaded box and at least one element in each unshaded exam of affected body area/system and other related systems (2-7 in more depth)Body Area(s) or Organ System(s)MEDICAL DECISION MAKING ('95 and '97 Guidelines)Exp Prob FocusedEXAM '97 Guidelines:General Multi-System ExamSingle Organ System ExamPerform and document 1-5 bulleted elements in one or more systems or body areasPerform and document at least 6 bulleted elements in one or more systems or body areasPerform all bulleted elements from at least 9 systems/body areas (unless specific directions limit content)

10 And document at least 2 bulleted elements from each selected areaPerform and document 1-5 bulleted elements, whether in shaded or unshaded boxPerform and document at least 12 bulleted elements (except for eye & psych exam, which should be at least 9 bulleted elements) whether in shaded or unshaded boxForm Date: 10/03/05 Level of Risk(2 of 3 elements must be met or exceeded to qualify for a level of Decision Making)Level of Decision Making_____High complexityExtensiveLimitedMultipleExtens iveHighLimitedMultipleRiskMinimalLowMode rateType of Med Dec MakingStraightforwardLow complexityModerate complexityDX/Mgmt OptionsDataMinimalMinimal or noneOne or more chronic illnesses with mild exacerbation, progression, or side effects of treatmentHighOne or more chronic illnesses with severe exacerbation, progression, or side effects of txPhysiologic tests under stress, , cardiac stress test.