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Single Organ System Exam Respiratory Created by The Lung Doctor Single Organ System Exam Respiratory Comprehensive Level Perform and document ALL elements in the following organ systems Perform and document at least 1 element in each of the following Constitutional ENT Inspection Neck Respiratory Cardiovascular Gastrointestinal Lymphatic Musculoskeletal Extremities Skin Neurologic Created by The Lung Doctor Single Organ System Exam Respiratory Constitutional Document at least 3 vital signs as follows Blood Pressure – Sitting OR Standing Blood Pressure – Lying Pulse – Rate AND Regularity Temperature Height Weight Note: May be measured and recorded by ancillary staff Created by The Lung Doctor Single Organ System Exam Respiratory Ears, Nose, Mouth, Throat Inspection of nasal mucosa, septum, turbinates Inspection of teeth and gums Examination of oropharynx Oral mucosa, hard and soft palates, tongue, tonsils, and posterior pharynx Created by The Lung Doctor Single Organ System Exam Respiratory Neck Examination of neck Masses, overall appearance, symmetry, tracheal position, crepitus Examination of thyroid Enlargement, tenderness, mass Examination of jugular veins Distension, a, v or cannon a waves Created by The Lung Doctor Single Organ System Exam Respiratory Respiratory Inspection of chest with notation of symmetry and expansion Assessment of respiratory effort Intercostal retractions, accessory muscle use, and diaphragmatic movement Percussion of chest Dullness, flatness, hyperresonance Palpation of chest Tactile fremitus Auscultation of lungs Breath sounds, adventitious sounds, rubs Created by The Lung Doctor Single Organ System Exam Respiratory Cardiovascular Auscultation of heart sounds, abnormal sounds and murmurs Examination of peripheral vascular system by observation and palpation Swelling and varicosities Pulses, temperature, edema, tenderness Created by The Lung Doctor Single Organ System Exam Respiratory Gastrointestinal (Abdominal) Examination of abdomen with notation of presence or absence of masses or tenderness Examination of liver and spleen Created by The Lung Doctor Single Organ System Exam Respiratory Lymphatic Palpation of lymph nodes Neck Groin Axilla Other location Note: Exam of at least 2 locations must be documented Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Musculoskeletal Assessment of muscle strength and tone with notation of any atrophy and abnormal movements Flaccid, cogwheel, spastic Examination of gait and station Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Extremities Inspection and palpation of digits and nails Clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Skin Inspection and/or palpation of skin and subcutaneous tissue Rashes, lesions, ulcers Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Neurological/Psychiatric Brief assessment of mental status Include orientation to person, time and place Include mood and affect – Anxiety, depression, agitation Created by The Lung Doctor
A concise summary of the medical documentation requirements for the respiratory single organ system exam. The documentation requirements for the history and medical decision making components are similar in all exam types, and can be reviewed in the Demystifying Medical Documentation presentation.
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