CMS WHAT TO SAY

HEART RATE

“Patient’s heart rate was 75 bpm, with a regular and consistent rhythm.”

RESPIRATION RATE

“Patient’s respiratory rate was 16 breaths per minute, with a consistent rhythm, normal depth, and no signs of labored breathing.”

BLOOD PRESSURE

“Patient’s blood pressure was over . Korotkoff sounds were heard clearly, with no indication of hypertension or hypotension.”

Heart Auscultation

“S1 and S2 heart sounds were heard in all five areas. No murmurs, rubs, or gallops detected. S1 was loudest at the apex, and S2 was loudest at the base. No S3 or S4 sounds were heard.”

JVP

“Jugular venous pressure was measured at __ cm, with no indication of elevated venous pressure.”

Auscultation (Anterior/Posterior Chest)

“Vesicular breath sounds were heard throughout all lung fields bilaterally.”

Egophony

“Patient vocalized ‘ee’ sounds which were heard as ‘ee’ throughout, with no indication of consolidation.”

Bronchophony / Whispered Pectoriloquy

“Spoken words were muffled and indistinct throughout, with no increased clarity, indicating no consolidation.”

Percussion (Chest)

“Resonant percussion sounds were heard throughout all lung fields bilaterally.”

Upper Limb DTR

“Deep tendon reflexes were 2+ bilaterally and symmetrical.”

Lower Limb DTR

“Deep tendon reflexes were 2+ bilaterally and symmetrical.”

Plantar Reflex

“Plantar reflex demonstrated a normal flexor response bilaterally.”

Rapid Alternating Movements

“Rapid alternating movements were performed smoothly, rhythmically, and symmetrically.”

Finger-to-Nose / Heel-to-Shin

“Movements were accurate, smooth, and coordinated with no dysmetria noted.”

Gait Assessment

“Gait was smooth, balanced, and coordinated. Patient was able to perform tandem, heel, and toe walking without difficulty.”

Romberg Test

“Romberg test was negative, with no loss of balance.”

Pronator Drift

“No pronator drift observed.”

EOMs/ Extra ocular movements

“Extraocular movements were intact in all directions, with no nystagmus observed.”

Pupillary Response to light and accomodation

“Pupils were equal, round, and reactive to light and accommodation.”

Abdominal Auscultation

“Bowel sounds were present and normal in all four quadrants.”

Abdominal Percussion

“Tympanic sounds were heard throughout, with no abnormal dullness.”

Light & Deep Palpation

“Abdomen was soft, non-tender, with no masses or guarding noted.”

McBurney’s Point

“No tenderness noted at McBurney’s point.”

Shifting Dullness

“No shifting dullness detected.”

Fluid Wave

“No fluid wave detected.”

Liver Percussion

“Liver dullness was detected within normal limits. liver measures at 8cm at the midclavicular and 5 cm at midsternal”

Liver Palpation

“Liver edge was not palpable and non-tender.”

Liver Span

“Liver span measured approximately 8 cm at midclavicular and 5cm at midsternal, within normal limits.”

Thyroid Inspection

“No visible enlargement or asymmetry of the thyroid gland.”

Thyroid Palpation

“Thyroid gland was smooth, non-tender, and without nodules.”

Spleen Percussion/ castles sign

“No splenic dullness detected.”

Spleen Palpation

“Spleen was not palpable.”

Otoscopy

“Visualization of the tympanic membrane was limited due to a narrow ear canal and presence of cerumen. If visualized, the tympanic membrane would appear intact, pearly grey, with normal landmarks and no signs of infection.”

Cervical Lymph Nodes

“No lymph nodes were palpable bilaterally, and there was no lymphadenopathy noted.”

SKIN EXAM

“The skin is intact with a few macules noted on the lower limbs. There are no concerning changes in pigmentation such as pallor, cyanosis, or jaundice. Skin is slightly dry, with normal temperature and smooth texture.”

OPHTHALMOSCOPIC EXAM

“Red reflex was present bilaterally. Due to visualization limitations, a full assessment was not possible. If visualized, I would assess the optic disc and retinal vasculature for any abnormalities.”