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Fam Pract Manag. 1998;5(4):9

The table of exam content and documentation requirements that appears in the Pocket Guide to the Documentation Guidelines and Quick-Reference List (see “Three Documentation Tools That Work,” January 1998) notes that “For the comprehensive exam, all bulleted elements must be performed.” This note is not meant to suggest that all 59 bulleted elements listed for the comprehensive exam must be performed. Rather, it addresses a distinction made in the guidelines for documenting multisystem exams, which is explained in an aptly titled article from our October 1997 issue, “Exam Documentation Just Got Harder.” While the guidelines require that at least 18 bulleted elements from at least nine systems or body areas be documented, they stipulate that all bulleted elements in the systems and areas examined be performed.


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