How to Document the Physical Exam

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The adage frequently cited in healthcare settings, “If it isn’t documented, it wasn’t done,” still rings true for the key components required in a patient’s medical record. The note in the medical record must sufficiently describe all of the services furnished to patients on a specific date.

The essential requirements to appropriately bill a claim and ultimately have it properly adjudicated involve reasonable documentation that the service(s) validate the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided.

The examination usually occurs after the provider obtains the chief complaint and history of present illness—the reason the patient is in the office, whether it’s a follow-up visit or to address an acute problem. Because the examination will be dictated by the patient’s complaint, it is safe to assume the exam could involve a single organ system, several organs and/or several areas. For example, if a patient presents with elbow pain, the provider would focus predominantly on examining the elbow and the arm to determine the extent of the paint. This enables the provider to base his/her judgment on what these findings are and how to treat. Keep in mind that one area of concern does not necessarily require a complete head-to-toe exam and should be determined on the basis of the findings. A head-to-toe examination is just that, depending on the severity of symptoms presented. A comprehensive exam requires a head-to-toe examination of the ears, eyes, nose, abdomen and extremities. All exams would need to be performed and documented.

Unlike the components of history and medical decision making, the rules defining the various levels of physical exam differ; two sets of guidelines exist—those from 1995 and those from 1997. The 1995 evaluation and management (E/M) guidelines allow the physician to complete the physical exam by documenting organ systems or body areas, which can be subjective but allows providers more leeway and “wiggle room.” On the other hand, the 1997 E/M guidelines are relatively rigid and force providers to document using more specificity through a bullet system. But the 1997 examination rules are much more black and white—either the bullets are there or they aren’t.

The levels of E/M services are based on four types of examination defined as follows:

• Problem Focused—A limited examination of the affected body area or organ system.
• Expanded Problem Focused—A limited examination of the affected body area or organ system and other symptomatic or related organ system(s).
• Detailed—An extended examination of the affected body area(s) and other symptomatic or related organ system(s).
• Comprehensive—A general multisystem examination or complete examination of a single organ system.

1995 E/M Guidelines Examination Rules

For the purpose of documenting an examination using the 1995 guidelines, the following body areas are recognized: