Table 2

1997 documentation guidelines: examination

Type of examinationNumber of organ system or body areasDescription
Problem-focusedAt least one organ systemOne to five elements identified by a bullet in at least one organ system
Expanded problem-focusedAt least one organ systemAt least six elements identified by a bullet in at least one organ system
DetailedAt least 2 elements each in six organ systems
OR
At least 12 elements in two or more organ systems
‘2 in 6’ At least two elements identified by a bullet in at least six organ systems
‘12 in 2’ Alternatively, may include at least 12 elements identified by a bullet in two or more organ systems
ComprehensiveTwo elements from at least nine organ systems or complete examination of single organ systemAt least nine organ systems or complete examination of single organ system