OUTPATIENT CONSULT NOTE NEW VISIT

Name: / DOB:
MR# / Requesting Physician:
Date:
CC:
HPI: Location  Severity  Timing  Quality  Duration  Context  Modifying Factor s  Assoc Signs/Symptoms
PF/EPF requires 1–3 elements (99201, 99241)
Detailed/Comprehensive require 4 elements or >3 chronic conditions (99203, 99204, 99205, 99243, 99244, 99245)
ROS:PF req. no documented ROS (99201, 99241)
EPF requires positives/pertinent negatives of symptom(s) related to HPI (99202, 99242)
Detailed requires positives and pertinent negatives of encountered system and at least one other system (2-9) (99203, 99243)
Comprehensive requires positives/pertinent negatives for 10+ systems or some systems w/ statement “All others negative”
(99204, 99205, 99244, 99245)
NormalAbnormal (comment on all abnormal)
 Constitutional
 Eyes
 Ears/Nose/Mouth/Throat
 Cardiovascular
 Respiratory
 Gastrointestinal
 Genitourinary
 Integumentary
 Musculoskeletal
 Neurologic
 Psychological
 Endocrine
 Hematologic/Lymphatic
 Allergic/Immunologic
PFSH:PF requires no documented PFSH (99201, 99241)
EPF requires no documented PFSH (99202, 99242)
Detailed requires one specific item from one of the three areas (past, family, social) (99203, 99243)
Comprehensive requires at least one item from each of the three areas (99204, 99205, 99244, 99245)
Past:
Family:
Social:
Name:Date:
Physical Exam:
- PF requires one to fiveelement from any system/area (99201, 99241)
- EPF requires at least 6 elements from any systems/area (99202, 99242)
- Detailed requires at least 12elements(99203, 99243)
- 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(99204, 99205, 99244, 99245)for 1997 DGs OR examination of 8 organ systems, varying detail for 1995 DGs
Constitutional
  • Measure any 3 Vital signs
  • 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
/ T______P______R______Wt______Ht ______
BP (Supine) ______BP (Sitting or Standing)______
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

Name:Date:
Assessment and Plan (Diagnosis, Risk, Order/Review of Data)

1

GYN exam OP Consult/New