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Generate physical exam templates
Write up the exam you actually performed, or build a reusable template with blanks and pick lists instead of pre-filled normal findings.
Describe what you examined in shorthand and River writes it up by system in clear clinical language, including measurements and grades as you gave them. Systems you did not examine are left out. Or ask for a reusable template for a visit type, built with blanks and short pick lists rather than pre-filled normal findings.
Pre-filled normal exam templates are convenient and risky: unchanged defaults end up describing examinations that never happened, and Medicare contractors have treated cloned documentation as failing to show medical necessity. This tool keeps the speed of a template without the defaults.
Documenting the exam you did
Be specific and record only what you examined. "Regular rate and rhythm, no murmur" says what was listened for; "normal" alone does not. Include measurements where they matter, such as edema grade, lesion size or range of motion, so the next examiner has a baseline.
Since the 2021 office visit changes, the exam needs to be medically appropriate rather than counted toward the visit level, so a focused exam that matches the complaint is enough. Keep reported symptoms in the history and observed findings in the exam.
How it works
Describe the exam
Your findings in shorthand, including what you did not examine.
River writes it up
Each finding placed under its system in full sentences, nothing added.
Check and paste
Review the write-up and paste it into the objective section of your note.
What you get
- Your exam written up by system in clear clinical language
- Only the systems you examined, with nothing normal filled in by default
- Measurements and grades carried exactly as you gave them
- Reusable templates with blanks and pick lists instead of pre-filled normals
- A clearly labelled learning reference for students, separate from patient notes
Common questions
Why doesn't it pre-fill normal findings?
Because unchanged defaults describe exams that did not happen, which misstates the visit and is a known audit risk. A template with blanks and pick lists is nearly as fast and records only what you found.
Should I document systems I did not examine?
No. Document what you examined. Under the 2021 office visit rules the exam only needs to be medically appropriate for the problem.
Can students use it to learn normal findings?
Yes. Choose the learning reference option for typical wording of normal and common abnormal findings by system, labelled as a reference and not for pasting into a patient's chart.
Can I include patient identifiers?
Follow your organization's policy. River is HIPAA-eligible and offers a Business Associate Agreement for work with identifiable information. Without one, leave out names, record numbers and dates of birth; the result reads the same, and you can add identifiers in your own record system.
Built by
Chandler Supple
Co-founder & CEO, River
Chandler has spent the last six years working in AI, building tools for millions of users and Fortune 100 companies. In 2025, he co-founded River to build a new kind of operating system for AI agents.
Generate physical exam templates
Describe what you need, add any files you have, and your workspace opens with the work already underway.