General Assessments

The general assessment is a comprehensive examination
conducted to establish a diagnosis, ascertain target
organ involvement, and develop an investigative
and treatment plan for a specific medical condition.
The physical examination should include all body
parts and systems relevant to the condition at issue
(e.g., if the presenting problem is chest pain, the
physician would examine the body parts that might
be involved, but might not conduct a pelvic or rectal
examination).
This type of encounter should be recorded as a general
assessment. Again, the CPP should be used to
review and update the patient’s medical history, family
and social history, ongoing health concerns or problem
list, immunizations, allergies, and medications.
The record of the visit should reflect all of the elements
of the physical examination.