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