Review of Systems
Constitutional
no yes
Weight loss
Musculoskeletal
no yes
Arthralgias
Fevers
Myalgias
Chills
Muscle weakness
Night sweats
Joint swelling
Fatigue
NSAID use
Other:
Patient: _____________________
Date: __________
Established Office Visit
2 out of 3 Key Components Required
E/M
Hx
Exam
MDM
99212
PF
PF
SF
99213
EPF
EPF
Low
99214
Det
Det
Mod
99215
Comp
Comp
High
Other:
Eyes
no yes
Skin
no yes
Time
10
15
25
40
Physical Exam
CONSTITUTIONAL
Record three vital signs
EYES
yes no
Pink conjunctivae; no ptosis
PERRLA
Fundi clear, no AV nicking
Rash
Eye pain
Pruritis
Chief Complaint:
Discharge
Sores
HPI
Dry eyes
Nail changes
Good dentition
Decreased vision
Skin thickening
Other:
Other:
No pharyngeal erythema
ENMT
Brief: 1 - 3 HPI elements* Extended: 4 HPI elements* or status of 3 problems
yes no
Nose and ears appear normal
NECK
no yes Neurological
no yes
yes no
Non-tender, no masses
Sore throat
Migraines
No thryomegaly or nodules
Tinnitus
Numbness
RESPIRATORY
Bloody nose
Ataxia
Normal respiratory effort
Hearing loss
Tremors
Sinusitis
Vertigo
Clear to auscultation
Other:
Other:
Respiratory
no yes
Endocrine
CARDIOVASCULAR
no yes
Excess thirst
Polyuria
RRR, no MRGs
Hemoptysis
Cold intolerance
No peripheral edema
Wheezing
Heat intolerance
GASTROINTESTINAL
Pleurisy
Goiter
Abdomen soft, with no masses
Other:
Other:
*HPI Elements: Location, Quality, Timing, Severity, Duration, Context, Modifying
Factors, Associated Signs and Symptoms
no yes
Depression
PND
Anxiety
Palpitations
Anti-depressants
FH
Edema
Alcohol abuse
SH
Orhtopnea
Drug abuse
Syncpe
Insomnia
Other:
Other:
Detailed: Ext HPI, 2 - 9 ROS, 1/3 PFSH
Bleeding diathesis
Diarrhea
Blood clots
Hematemesis
Swollen glands
Lymphedema
Other:
Other:
no yes Allrgic/Immun
Hematuria
Allergic rhinitis
Dysuria
Hay fever
Hesitancy
Asthma
Incontinence
Positive PPD
Hives
Other:
Other:
4
3
1
2
no yes
SKIN
Comp: Ext HPI, 10 ROS, 2/3 PFSH
No rashes, ulcers or lesions
NEUROLOGIC
yes no
CNs intact
No sensory deficits
DTRs intact and symmetrical
PSYCHIATRIC
yes no
Appropriate affect
no yes
A&OX3
Intact judgment and insight
Data Points
1
yes no
Normal turgor and temperature
Data Reviewed
Sa
Melena
UTIs
No digital cyanosis or clubbing
EPF: Brief HPI, 1 ROS, no PFSH
m
Vomiting
yes no
Normal gait and station
Levels of History
Easy bruising
Genitourinary
MUSCULOSKELETAL
Problem Focused: Brief HPI, no ROS/PFSH
Nausea
No hepatosplenomegaly
Heme occult negative
PMH
Hem/Lymphatic
yes no
No hernias
Pertinent Past Medical, Family and Social History
Chest pain
Gastrointestinal no yes
pl
e
Psychiatric
yes no
No carotid bruits
Cough
no yes
yes no
Clear to percussion
Short of breath
Cardiovascular
Abnormal
Findings
Conversant/NAD
Blurry vision
Ears/Nose/
Throat
yes no
Review
and/or
order labs
Review and/
or order Xrays
Review and/or order
medical test (PFTs,
EKG, echo, cath)
Discuss
test with
MD
Review any
image, tracing,
specimen
Order
old
records
Summarize
old records
1
1
1
1
2
1
2
Assessment (Assign problem points)
PF = 1 - 5 bullets.
EPF = 6 - 11 bullets.
Detailed = 12 bullets.
Comprehensive = 2 bullets from EACH of NINE systems
Plan
Established, stable
Established, not controlled
Self-limited or minor (max 2)
New, no further w/u planned
New, further w/u is planned
99212
99213
MDM
SF
Low
Mod
High
Minimal Risk
•One self limited problem
(e.g., cold, insect bite)
Prob Pts
≤1
2
3
≥4
Data Pts
1
2
3
4
99214
Risk
Min
Low
Mod
High
99215
______________________________________
Signature
Only 2 out of 3 MDM dimensions required
Low Risk
• Two self-limited problems
• One stable chronic illness
• Acute uncomplicated illness
(e.g., cystitis/rhinitis)
• OTC drugs
Moderate Risk
• Mild exacerbation of one chronic illness
• Two stable chronic illnesses
• Undiagnosed new problem
• Acute illness with systemic symptoms
(e.g., pyelonephritis, colitis)
• Prescription drug management
High Risk
• Severe exacerbation of chronic illness
• Illness with threat to life or bodily function
• Abrupt change in neurological status (e.g., TIA/weakness)
• Parenteral controlled substances
• Decision for DNR or to de-escalate care
• Drugs requiring intensive monitoring for toxicity