AUDIT WORKSHEET
Problem
Focused
Exp. Prob.
Focused
Detailed
Comprehensive
Brief (1-3)
Brief (1-3)
Extended
(4+)
Extended
(4+)
None
Pertinent
to problem
(1 system)
Extended
(2-9
systems)
None
None
Pertinent
(1)
Complete*
(2 or 3)
1 body
area or
system
Up to 7
systems
Up to 7
systems
8 or more
systems
HISTORY
HPI Elements
Location
Severity
Timing
Modifying factors
Quality
Duration
Context
Associated signs and symptoms
ROS:
Constitutional (wt
loss, etc)
Ears, nose, mouth, throat
Eyes
Card/vasc
GI
Integumentary (skin, breast)
GU
Hem/Lymph
Musculo
Neuro
All/Imm
Psych
"All others negative"
Past history
Family history
Social history
Abdomen
Back, incl. spine
Each extremity
Resp
PFSH:
Endo
Complete
(10+ or some
systems w/
statement "all
others negative")
Body Areas:
EXAM
Head, incl. face
Chest, incl. breasts and
axillae
Neck
Genitalia, groin, buttocks
Organ Systems:
Constitutional (e.g.
vitals, gen app)
Ears, nose, mouth, throat
Eyes
Cardiovascular
* Complete PFSH:
Resp
Musculo
Psych
GI
Skin
Hem/Lymph/Imm
GU
Neuro
2 hx areas: a) Est pts office (outpt) care; domiciliary care; home care b) Emergency dept c) Subseq nursing facility care
3 hx areas: a) New pts office (outpt) care; home care b) Consultations c) Initial hospital care d) Hospital observation
e) Compre nursing facility assessments
Number of Diagnoses or Treatment Options
Risk of Complications and/or Morbidity or Mortality
B
Problems to Exam Physician
Number
Points
Self-limited or minor (stable, improved or
worsening)
Max=2
Est. problem (to examiner); stable, improved
Est. problem (to examiner); worsening
New problem (to examiner); no addl workup
planned
Max=1
Result
Level
of Risk
MINIMAL
Presenting Problem(s)
*Lab tests requiring
venipuncture
insect bite, tinea corporis
*Chest x-rays
*Rest
*Gargles
*Elastic bandages
*EKG/EEG
*Superficial dressings
*Urinalysis
*Ultrasound, e.g. echo
*KOH prep
*Two or more self-limited *Physiologic tests not
or minor problems
under stress, e.g.
LOW
pulmonary function tests
*One stable chronic
illness, e.g. well-controlled
HTN or DM, cataract, BPH
Amount and/or Complexity of Data to Be Reviewed
Review and/or order of clinical lab tests
cystitis, sprain, allergic rhinitis
Review and/or order of tests in the radiology section of CPT
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
*One or more chronic
illnesses with mild
exacerbation,
progression, or side
effects of treatment
Review and summarization of old records and/or obtaining history from
someone other than patient and/or discussion of case with another health
care provider
Independent visualization of image, tracing, or specimen itself (not simply
review of report)
2
2
MODERATE
Decision to obtain old records and/or obtain history from someone other
than patient
*Two or more stable
chronic illnesses
*Undiagnosed new
problem with uncertain
prognosis, e.g. lump in
breast
*Acute illness with
systemic symptoms, e.g.
TOTAL
Final Medical Decision Making - 2/3
Highest risk
Minimal
Amount and complexity of data
MDM
2 Limited 3 Multiple
Low
Moderate
4
Extensive
High
1
3
4
Minimal or 2 Limited Moderate Extensive
low
Low
StraightModerate
High
forward Complex. Complex. Complex.
*Over-the-counter drugs
*Minor surgery with no
identified risk factors
*Physical therapy
*Occupational therapy
*Superfcl needle biopsies *IV fluids without
*Skin biopsies
additives
*Physiologic tests
*Minor surgery with
under stress, e.g. cardiac identified risk factors
stress test, fetal contraction
*Elective major surgery
stress test
*Diagnostic
endoscopies with no
identified risk factors
*Deep needle or
incisional biopsy
*CV imaging studies
with contrast and no
identified risk factors,
(open, percutaneous, or
endoscopic) with no
identified risk factors
*Prescription drug
management
*Therapeutic nuclear
medicine
*IV fluids with additives
*Acute complicated
injury, e.g. injury with brief
*Closed treatment of
fracture of dislocation
*Obtain fluid from body without manipulation
cavity, e.g. lumbar
loss of consciousness
puncture, thoracentesis
*One or more chronic
illnesses with severe
exacerbation,
progression, or side
effects of treatment
*Cardiovascular
imaging studies with
contrast with identified
risk factors
*Elective major surgery
(open, percutaneous, or
endoscopic) with
identified risk factors
*Cardiac
electrophysiological
tests
*Emergency major
surgery (open,
percutaneous, or
endoscopic)
pneumonitis, colitis
1
Minimal
*Non-cardiovascular
imaging studies with
contrast, e.g. barium
enema
*Acute uncomplicated
illness or injury, e.g.
Points
HIGH
MEDICAL DECISION MAKING
TOTAL
Data to Be Reviewed
Management Options
Selected
*One self-limited or
minor problem, e.g. cold,
New problem (to examiner); addl workup planned
Number diagnoses or management
options
Diagnostic
Procedure(s) Ordered
*Acute or chronic
illnesses or injuries that
may pose a threat to life
or bodily function, e.g.
e.g. arteriogram, cardiac
cath
*Diagnostic
endoscopies with
identified risk factors
multiple trauma, acute MI,
pulmonary embolus, severe
respiratory distress,
*Discography
psychiatric illness w/ potential
threat to self or others,
peritonitis, acute renal failure
*An abrupt change in
neurologic status, e.g.
seizure, TIA, weakness,
sensory loss
*Parenteral controlled
substances
*Drug therapy requiring
intensive monitoring for
toxicity
*Decision not to
resuscitate or to deescalate care due to
poor prognosis
