What is required for a detailed examination according to the 1995 Documentation Guidelines?

A detailed examination, as defined by the 1995 Documentation Guidelines, necessitates a comprehensive assessment that demonstrates the depth of the examination across multiple areas of the body. Specifically, this requires elaboration of findings for at least two areas to ensure that a significant portion of the patient's health status is thoroughly evaluated. This standard emphasizes the need for adequate documentation that reflects not only a cursory look at the patient's condition but also a nuanced understanding of their health.

When documenting a detailed examination, healthcare providers are encouraged to describe specific findings and the implications those findings have on patient care and treatment decisions. This level of detail supports appropriate coding and billing practices and helps ensure quality of care. Thus, the requirement to elaborate findings for at least two areas distinguishes a detailed examination from the more basic or general assessments, providing a clearer, more comprehensive picture of the patient’s condition.