Problem-focused examination

1995 documentation guidelines: limited examination of the affected body area or organ system. The health record should describe only one body area or organ system. 1997 documentation guidelines for multisystem examination: performance and documentation of one to five elements identified by a bullet (•) in one or more body or system areas. 1997 documentation guidelines for single organ system examination: performance and documentation of one to five elements identified in a table by a bullet (•), whether in a shaded or unshaded box.

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