Physical examination documentation represents an essential component of medical records. Yet medical students spend significant time learning proper terminology and format for documenting findings. According to medical education research, standardized templates improve documentation completeness and reduce errors among learners. Templates ensure systematic examination documentation covering all required elements.
What 11 Systems Should Physical Exam Include?
Complete Physical Exam Systems
| # | System | Key Components |
|---|---|---|
| 1 | Vital Signs | BP, HR, RR, Temp, O2 sat, Weight |
| 2 | General | Appearance, alertness, distress, habitus |
| 3 | HEENT | Pupils, EOM, oropharynx, TMs |
| 4 | Neck | Thyroid, lymph nodes, JVD, carotids |
| 5 | Cardiovascular | Rate, rhythm, sounds, murmurs, edema, pulses |
| 6 | Respiratory | Effort, lung sounds, percussion |
| 7 | Abdomen | Bowel sounds, tenderness, masses, organomegaly |
| 8 | Musculoskeletal | Joints, strength, ROM, deformity |
| 9 | Neurological | Cranial nerves, motor, sensory, reflexes, gait |
| 10 | Skin | Lesions, rashes, color, turgor |
| 11 | Psychiatric | Mood, affect, thought process, insight |
Normal Physical Exam Template
**VITAL SIGNS:** BP 120/78, HR 72 regular, RR 14, Temp 98.6°F, O2 sat 98% RA **GENERAL:** Well-appearing, alert and oriented x3, no acute distress, appropriate body habitus **HEENT:** PERRLA, EOMI, oropharynx clear without erythema or exudate, TMs intact bilaterally **NECK:** Supple, no lymphadenopathy, thyroid non-enlarged, no JVD, no carotid bruits **CARDIOVASCULAR:** Regular rate and rhythm, S1 and S2 normal, no murmurs/rubs/gallops, peripheral pulses 2+ bilaterally, no edema **RESPIRATORY:** Non-labored breathing, lungs clear to auscultation bilaterally, no wheezes/rhonchi/rales **ABDOMEN:** Soft, non-tender, non-distended, normoactive bowel sounds, no masses or organomegaly **MUSCULOSKELETAL:** Full ROM all extremities, strength 5/5 throughout, no joint swelling or deformity **NEUROLOGICAL:** CN II-XII intact, motor strength 5/5 all extremities, sensation intact to light touch, reflexes 2+ and symmetric, gait normal **SKIN:** Warm, dry, no rashes or lesions **PSYCHIATRIC:** Alert, cooperative, appropriate mood and affect, thought process linear
Abnormality Grading Scales
Standard Clinical Scales
| Finding | Scale | Interpretation |
|---|---|---|
| Muscle strength | 0-5 | 0=no contraction, 5=full strength |
| Reflexes | 0-4+ | 0=absent, 2+=normal, 4+=hyperactive with clonus |
| Edema | 1+ to 4+ | 1+=trace, 4+=severe pitting |
| Heart murmurs | 1/6 to 6/6 | 1=barely audible, 6=audible without stethoscope |
| Pulses | 0-4+ | 0=absent, 2+=normal, 4+=bounding |
How to Document Abnormal Findings Specifically
Vague documentation: "Abnormal heart sounds" (provides no clinical value)
Specific documentation: "Grade 3/6 holosystolic murmur best heard at apex with radiation to axilla" (communicates precise finding)
Include anatomic specificity: "2cm tender mobile mass in right upper outer quadrant of left breast at 10 o'clock position, 5cm from nipple" (enables localization and follow-up)
Problem-Focused Exam Documentation
Match documentation depth to clinical indication:
- Comprehensive visit: Document all 11 systems
- Problem-focused visit: Detailed exam of relevant systems, abbreviated for others
- Example (knee pain): Detailed MSK of affected knee, brief normal documentation for other systems
Specialty-Specific Exam Templates
Specialty Adaptations
| Specialty | Emphasis | Special Elements |
|---|---|---|
| Orthopedics | Detailed MSK | Special tests (Lachman, McMurray) |
| Dermatology | Skin examination | Body diagrams, lesion morphology |
| Neurology | Neurological exam | Standardized scales (NIHSS, MoCA) |
| Cardiology | CV examination | JVP measurement, detailed murmur description |
Common Documentation Mistakes to Avoid
- Documenting exam not performed: Creates medicolegal risk if disproven
- Contradictory HPI and exam: "Severe pain" with "non-tender" exam needs explanation
- Insufficient abnormal detail: Future providers need specifics for tracking
- Process over findings: "Auscultation performed" vs. "Lungs clear bilaterally"
Frequently Asked Questions About Physical Exam Documentation
When can I use abbreviations in documentation?
Use only approved, universally recognized abbreviations. PERRLA, EOMI, RRR are standard. Avoid obscure or institution-specific abbreviations. When in doubt, write it out.
How detailed should normal findings be?
Detailed enough to confirm examination was thorough. "Cardiovascular: Normal" is insufficient. "RRR, no murmurs/rubs/gallops, pulses 2+, no edema" confirms what was assessed and found normal.
Should I document negative findings?
Yes, for symptom-relevant systems (pertinent negatives). Chest pain evaluation should explicitly document: "No JVD, no carotid bruits, no murmurs, no S3 or S4." Explicit negatives show thorough assessment.
Can I reference prior exams for stable patients?
Yes, with caveats. "Physical exam unchanged from [date]" is acceptable for stable chronic visits if you actually examined the patient. Never copy forward without re-examining.
Can AI help generate exam documentation?
Yes, AI tools like River's Physical Exam Generator create complete documentation. Select systems, indicate normal vs. abnormal findings, and the AI generates properly formatted documentation with correct medical terminology. Always verify accuracy before finalizing.
AI physical examination templates accelerate documentation while teaching proper terminology essential for professional medical records. Use River's Physical Exam Generator to create well-structured examination documentation that captures clinical findings accurately.