Provider: DOS: Coded/Documented: / Auditor:

= least score of the three history sections, assuming CC present.
Patient Type:
(to practice):    (to provider):
Chief Complaint:
History of Present Illness:
Problem Type (to provider):
(Hold down 'Ctrl' key to select multiple)
Review of Systems:
Past, Family, and Social History:
Physical Exam:
1995 Guidelines:
1997 Guidelines:
(MSK exam involves evaluation of joints, bones and muscles including ROM, stability and strength)
(scored by # elements: 1=1-5, 2=6-11, 3=12-17 and 6 systems, 4=18+ and 9 systems)
= middle score of three sections
Number of Diagnoses:
(include all problems discussed)
Self-limited or minor problems:
Established problem to examiner stable or improved:
Established problem to examiner worsening:
New problem to examiner no workup:
New problem to examiner additional workup:
Data Reviewed:
Medical Risk:
Visit CPT Code: