Posted: June 24th, 2016

Complete Physical Examination-Mandatory Components:

Complete Physical Examination-Mandatory Components:
[excluding the pelvic exam, breast exam, genitourinary exam for male or female]
Vital signs: Temperature, Pulse, Respirations and Blood Pressure, Weight and Height, Body Mass Index (BMI).
Mental Status Exam (MSE) – Document the MSE in narrative, paragraph form:
1st paragraph – summary of presentation (appearance,
behaviour, speech, language)
2nd paragraph – key findings with mood & affect
3rd paragraph – thought processes
4th paragraph – cognitive function
5th & final – insight & judgment
Skin (include hair and nails)
Head (include regional lymph nodes)
Eyes
Ears
Nose and Sinuses
Mouth and Throat
Neck (include regional lymph nodes)
Respiratory (include regional lymph nodes)
Cardiovascular and Peripheral Vascular
Abdomen (include regional lymph nodes)
Musculoskeletal
Neurological
Document the regional lymph nodes with the specific name of the nodes that you checked. Failure to name the specific nodes will result in point deduction
(E.g., writing “no lymphadenopathy” in the neck exam is not correct. You must name the nodes you checked and what your findings were, whether abnormal or normal.
Include the cranial nerves (CN) within the body system where you checked the CN. For instance, when you are examining the ear, you will document that CN VIII is intact as the pt passed the whisper test. Then in the Neurological system, if all of the CN testing demonstrates that the CNs are intact, you may chart CNI-CNXII intact. You may not document that all of the CNs are intact unless there is previous documentation that you have specifically tested the CN within the body system.