Residents are expected to see all emergency room consults, inpatient consults, and new non-surgical inpatient admissions. Documentation of these services should conform to national E&M coding standards and should be dictated immediately after the encounter into the Shands dictation system. A handwritten note should also be placed in the patient's chart, documenting the pertinent positives, the diagnosis, and the recommendations for treatment. The patient should be presented to the attending physician as soon as possible. A template for Level 3 services follows:
Department of Neurosurgery
New Inpatient (99221) or Consult (99253) E&M Template
Step 1: Opening Statement and Chief Complaint
1. Consult - The X year old male/female is seen at the request of Dr. “Attending
Physician” in consultation for....”
2. New Patient - The X year old male/female is seen for the first time for evaluation of .......”
Step 2: Detailed History
Extended History of Present Illness: 4 or more elements
Extended Review of Systems: a minimum of 2 systems
Pertinent Past Medical History: Medical Illnesses, Surgery, Allergies, Meds
Optional: Family History, Social History
Step 3: Detailed Physical Exam (at least 12 elements for the following list)
Constitutional
Measurement of any three of the following seven vital signs: sitting or standing blood pressure, supine blood pressure, pulse rate and regularity, respiration,
temperature, height, weight
Eyes
Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance)
and posterior segments (e.g. vessel changes, exudates, hemorrhages)
Musculoskeletal
Examination of gait and station
Muscle strength in the upper and lower extremities
Muscle tone in the upper and lower extremities (e.g., flaccid, cog wheel, spastic)
with notation of any atrophy or abnormal movements (e.g. fasciculation, tardive
dyskinesia)
Neurological
Orientation to time, place, person
Recent and remote memory
Attention span and concentration
Language (e.g., naming objects, repeating phrases, spontaneous speech)
Fund of knowledge (e.g., awareness of current events, past history, vocabulary)
2nd cranial nerve (e.g., visual acuity, visual fields, fundi)
3rd, 4th, and 6th cranial nerves (e.g., pupils, eye movements)
5th cranial nerve (e.g., facial sensation, corneal reflexes)
7th cranial nerve (e.g., facial symmetry, strength)
8th cranial nerve (e.g., hearing with tuning fork, whispered voice and/or finger rub)
9th cranial nerve (e.g., spontaneous or reflex palate movement)
11th cranial nerve (e.g., shoulder shrug strength)
12th cranial nerve (e.g., tongue protrusion)
Examination of sensation (e.g., by touch, pin, vibration, proprioception)
Examination of deep tendon reflexes in upper and lower extremities with notation of pathological reflexes (e.g., Babinski)
Test coordination (e.g. finger/nose, heel/knee/shin, rapid alternating movements
in the upper and lower extremities, evaluation of fine motor coordination in young
children)
Cardiovascular
Auscultation of carotid arteries (e.g., pulse amplitude, bruits)
Auscultation of heart with notation of abnormal sounds and murmurs
Examination of peripheral vascular system by observation (e.g., swelling, varicosities) and palpation (e.g. pulses, temperature, edema, tenderness)
Step 4: Medical Decision Making (Low Complexity)
Data review: At least two
Diagnosis/Management options: At least two
Risk of Complications: At least low
Cc: Dr. “Attending Physician”
Remember: If the patient is unable to give full history or cannot cooperate with full exam, you still get credit if you document that issue.
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