What's the difference in physical exam types? Bullets and 1997.

I actually have seen these in a few shrouded away places...But most physicians don't know these rules......You see, in 1997 the EM physical exam rules were updated from the loosey goosey rules of 1995.....They rely on these "Bullet Points" which allow atomatons to check the boxes and audit our charts much easier. It also allows for the automation and creation of EMR exam forms....i.e. "check the box" or "Check the Bullets"

Here are the 1997 Physical Exam Rules, Couched with levels of physical examination.

1997 Physical Exam Rules General Multi-System Exam 1997 Problem Focused Exam One to five bullets from one or more organ systems Example  Vitals: 120/80, 88, 98.6  General appearance: NAD, conversant  Lungs: CTA  CV: RRR, no MRGs  (1 bullet for three vital signs)  (1 bullet for general appearance)  (1 bullet for auscultation of lungs)  (1 bullet for auscultation of the heart) Total bullets = four (although only one to five bullets are required)  1997 Expanded Problem Focused Exam  At least two bullets from six organ systems OR 12 bullets from two or more organ systems  Example  Vitals: 120/80, 88, 98.6  General appearance: NAD, conversant Lungs: Clear to auscultation  CV: RRR, no MRGs  Abdomen: Soft, nontender  Extremities: No peripheral edema  (1 bullet for three vital signs)  (1 bullet for general appearance)  (1 bullet for auscultation of lungs)  (1 bullet for auscultation of the heart)  (1 bullet for examination of the abdomen)  (1 bullet for examination of extremities for edema)  Total bullets = six  1997 Detailed Exam  At least two bullets from six organ systems OR 12 bullets from two or more organ systems Example  Vitals: 120/80, 88, 98.6  General appearance: NAD, conversant  Neck: FROM, supple  Lungs: Clear to auscultation  CV: RRR, no MRGs; normal carotid upstroke and amplitude without bruits  Abdomen: Soft, non-tender; no masses or HSM  Extremities: No peripheral edema or digital cyanosis Skin: no rash, lesions or ulcers  Psych: Alert and oriented to person, place and time  (1 bullet for three vital signs)  (1 bullet for general appearance)  (1 bullet for examination of neck)  (1 bullet for auscultation of lungs)  (1 bullet for auscultation of the heart)  (1 bullet for assessment of carotid arteries)  (1 bullet for examination of the abdomen)  (1 bullet for examination of liver and spleen)  (1 bullet for examination of extremities for edema)  (1 bullet for examination and/or palpation of digits and nails)  (1 bullet for inspection of skin and subcutaneous tissue)  (1 bullet for brief assessment of mental status—orientation) Total bullets = 12  1997 Comprehensive Exam  Two bullets from EACH of nine organ systems Example  Vitals: 120/80, 88, 98.6  General appearance: NAD, conversant  Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA  HENT: Atraumatic; oropharynx clear with moist mucous membranes and no mucosal ulcerations; normal hard and soft palate  Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy  Lungs: CTA, with normal respiratory effort and no intercostal retractions  CV: RRR, no MRGs  Abdomen: Soft, non-tender; no masses or HSM  Extremities: No peripheral edema or extremity lymphadenopathy Skin: Normal temperature, turgor and texture; no rash, ulcers or subcutaneous nodules  Psych: Appropriate affect, alert and oriented to person, place and time  Systems and Bullets  Constitutional  (1 bullet for three vital signs)  (1 bullet for general appearance)  Eyes  (1 bullet for inspection of conjunctivae and lids)  (1 bullet for examination of pupils and irises)  Ears, Nose, Mouth and Throat  (1 bullet for external inspection of ears and nose—“atraumautic”)  (1 bullet for examination of oropharynx)  Neck  (1 bullet for examination of neck)  (1 bullet for examination of the thyroid)  Respiratory  (1 bullet for auscultation of lungs)  (1 bullet for assessment of respiratory effort)  Cardiovascular  (1 bullet for auscultation of heart)  (1 bullet for examination of extremities for edema or varicosities)  Gastrointestinal  (1 bullet for examination of the abdomen)  (1 bullet for examination of liver and spleen)  Lymphatic  (1 bullet for examination of lymph nodes in neck)  (1 bullet for examination of lymph nodes in extremities)  Skin  (1 bullet for inspection of skin and subcutaneous tissues)  (1 bullet for palpation of skin and subcutaneous tissues)  Psychiatric  (1 bullet for description of patient’s judgment and insight)  (1 bullet for brief assessment of mental status—orientation)  Total systems = 10 (although only nine are required)  Total bullets = 20 (although only 18 are required—two in EACH of nine systems)  Organ Systems  The 1997 E/M guidelines recognize the following organ systems:  1. Constitutional  2. Eyes  3. Ears, nose, mouth and throat  4. Neck  5. Respiratory  6. Cardiovascular  7. Chest (breasts)  8. Gastrointestinal (abdomen)  9. Genitourinary (male)  10.Genitourinary (female)  11. Lymphatic  12. Musculoskeletal  13. Skin  14. Neurologic  15. Psychiatric Physical Exam Bullets  Constitutional      1)   Three vital signs     2)    General appearance Eyes      1)   Inspection of conjunctivae and lids      2)   Examination of pupils and irises (PERRLA)      3)   Ophthalmoscopic discs and posterior segments  Ears, Nose, Mouth, and Throat      1)   External appearance of the ears and nose (overall appearance, scars, lesions, masses)      2)   Otoscopic examination of the external auditory canals and tympanic membranes      3)   Assessment of hearing      4)   Inspection of nasal mucosa, septum and turbinates      5)   Inspection of lips, teeth and gums      6)   Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx Neck      1)   Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)      2)   Examination of thyroid  Respiratory      1)   Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)      2)   Percussion of chest (e.g., dullness, flatness, hyperresonance)      3)   Palpation of chest (e.g., tactile fremitus)      4)   Auscultation of the lungs Cardiovascular      1)   Palpation of the heart (location, size, thrills)      2)   Auscultation of the heart with notation of abnormal sounds and murmurs      3)    Assessment of lower extremities for edema and/or varicosities      4)   Examination of the carotid arteries (e.g., pulse amplitude, bruits)      5)   Examination of abdominal aorta (e.g., size, bruits)      6)   Examination of the femoral arteries (e.g., pulse amplitude, bruits)      7)    Examination of the pedal pulses (e.g., pulse amplitude) Chest (Breasts)      1)   Inspection of the breasts (e.g., symmetry, nipple discharge)      2)   Palpation of the breasts and axillae (e.g., masses, lumps, tenderness) Gastrointestinal (Abdomen)      1)   Examination of the abdomen with notation of presence of masses or tenderness      2)   Examination of the liver and spleen      3)   Examination for the presence or absence of hernias      4)   Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids,            rectal masses      5)   Obtain stool for occult blood testing when indicated Genitourinary (Male)      1)    Examination of the scrotal contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular mass)      2)   Examination of the penis      1)   Digital rectal examination of the prostate gland (e.g., size, symmetry, nodularity, tenderness) Genitourinary (Female)  Pelvic examination (with or without specimen collection for smears and cultures, which may include:      1)   Examination of the external genitalia (e.g., general appearance, hair distribution, lesions)      2)   Examination of the urethra (e.g., masses, tenderness, scarring)      3)    Examination of the bladder (e.g., fullness, masses, tenderness)      4)   Examination of the cervix (e.g., general appearance, discharge, lesions)      5)   Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)      6)    Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity) Lymphatic  Palpation of lymph nodes two or more areas:      1)   Neck      2)    Axillae      3)    Groin      4)   Other Musculoskeletal      1)   Examination of gait and station      2)   Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia,           infections, nodes) Examination of the joints, bones, and muscles of one or more of the following six areas:      a)   head and neck      b)    spine, ribs, and pelvis      c)    right upper extremity      d)   left upper extremity      e)   right lower extremity      f)    left lower extremity The examination of a given area may include:   1)   Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation,   2)   defects, tenderness, masses or effusions  3)   Assessment of range of motion with notation of any pain, crepitation or contracture  4)  Assessment of stability with notation of any dislocation, subluxation, or laxity   5)  Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with notation of any  atrophy or abnormal movements Skin      1)   Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)     2)   Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening) Neurologic      1)    Test cranial nerves with notation of any deficits      2)   Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi)      3)   Examination of sensation (e.g., by touch, pin, vibration, proprioception) Psychiatric      1)   Description of patient’s judgment and insight Brief assessment of mental status which may include     1)   orientation to time, place, and person     2)   recent and remote memory     3)   mood and affect 1997 Specialty Exams can be found here. So there you have it......if you have the time to read through this and understand, you can see that the more you document the better. If you do use an EMR, you probably all ready have this. But if you are on paper, you should update your exam form to include the systems and perhaps even the bullets. This will prompt you to examine "All the pertinent systems" Want to join us? Email us at modifier25@gmail.com