OUTPATIENT
Name:
Name:
MR#
Symptoms:
 ESTABLISHED VISIT
Date
Appt Time:
Date:
TELE:
DOB:
Diag:
Established visit requires two of the three (History, Exam and/or Medical Decision Making)
HPI:  Location  Severity  Timing  Quality  Duration  Context  Modifying Factor s  Assoc Signs/Symptoms
PF/EPF requires 1 - 3 elements (99212, 99213)
Detailed/Comprehensive require 4 elements or >3 chronic conditions (99214, 99215)
History Form of ___/___/___ reviewed. Changes in ROS and/or PFSH as follows:
ROS: PF requires no documented ROS (99212)
EPF requires positives & pertinent negatives of symptom(s) related to HPI (99213)
Detailed requires positives and pertinent negatives of encountered system and at least one other system (2–9) (99214)
Comprehensive req. positives/pertinent negatives for 10+ systems or some systems w/statement “all others negative” (99215)
Normal Abnormal (comment on all abnormal)
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Constitutional
Eyes
Ears/Nose/Mouth/Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Integumentary
Musculoskeletal
Neurologic
Psychological
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
PFSH: PF requires no documented (99212)
EPF requires no documented history (99213)
Detailed requires one specific item from one of the three areas (past, family, social) (99214)
Comprehensive requires at least one item from each of the three areas (99215)
Past:
Family:
Social:
GYN exam OP Established
1
Physical Exam:
-
PF requires one to five element from any system/area (99212)
EPF requires at least 6 elements from any systems/area (99213)
Detailed requires at least 12 elements (99214)
Comprehensive requires every element under constitutional and gastrointestinal, 7 of the 11 elements under genitourinary
and at least 1 element in each unbolded system/body area (99215) for 1997 DGs OR examination of 8 organ systems, detail
may vary for 1995 DGs
Constitutional
 Measure any 3 Vital signs
T__________ P__________ R__________ Wt__________ Ht __________
BP (Supine) __________ BP (Sitting or Standing)__________
 General Appearance
Neck:
 Examination of neck
 Examination of thyroid
Respiratory
 Assessment of respiratory effort
 Auscultation of lungs
Cardiovascular
 Auscultation of heart
 Examination of peripheral
vascular system by observation
Chest (Breast)
See genitourinary (female)
Gastrointestinal (Abdomen)
 Examination of abdomen
with notation o f presence
of masses or tenderness
 Examination for presence
or absence of hernia
 Examination of liver and
spleen
 Obtain stool sample for
occult blood test when
indicated
GYN exam OP Established
2
Name:
Date:
Genitourinary
 Inspection and palpation of
breasts
 Digital rectal examination
including sphincter tone,
presence of hemorrhoids,
rectal masses
Pelvic examination (w/ or w/o
specimen collection for smears
and cultures):
 External genitalia
 Urethral meatus
 Urethra
 Bladder
 Vagina
 Cervix
 Uterus
 Adnexa/parametria
 Anus and perineum
Lymphatic:
 Palpation of lymph nodes in
neck, axillae, groin and/or other
location
Skin:
 Inspection and/or palpation of
skin and subcutaneous tissue
Neurological/Psychiatric
Brief assessment of mental status
including:
 Orientation
 Mood and affect
GYN exam OP Established
3
Name:
Date:
Assessment and Plan
(Diagnosis, Risk, Order/Review of
Data)
GYN exam OP Established
4