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The Patient Exam What Really Matters Focus on what’s medically relevant, such as the patient’s complaints. Why is that? For the patient exam, the medically relevant elements are determined by the patient's complaints and ultimately, what the physician deems medical necessity for the encounter. Focus on performing and document a medically appropriate exam. And remember, You don’t need to count every element. But, Details like orientation to time and plan or mood and affect only need documen