Generate physical exam templates
AI creates complete physical exam documentation with normal findings for any organ system, ready to customize with your patient's actual findings.
Generate physical exam templates
River's Physical Exam Template Generator creates complete physical exam documentation with normal findings by organ system. You select which systems to examine, and the AI generates professional PE documentation with appropriate normal findings that you customize with your patient's actual exam results. The templates include proper terminology, systematic organization, and all relevant exam components. Perfect for medical students learning exam documentation, residents working efficiently, or any clinician wanting well-structured physical exam templates.
Unlike abbreviated or inconsistent exam documentation, these templates ensure you document all relevant exam elements systematically. Complete physical exam documentation demonstrates thoroughness, supports clinical decision-making, and meets billing requirements. The AI provides normal findings as starting point that you modify based on your actual examination. When physical exams are documented completely and systematically, they provide better clinical information and legal protection.
This tool is perfect for medical students learning proper PE documentation, residents documenting efficiently during busy shifts, attending physicians ensuring complete notes, or any clinician wanting systematic exam templates. If your exam documentation is incomplete or inconsistent, these templates provide professional structure. Use them for any patient encounter requiring physical examination documentation.
Documenting Physical Exams Well
Good physical exam documentation is specific, systematic, and supports your clinical reasoning. State what you examined and what you found. Avoid vague terms like 'normal' or 'unremarkable' without detail. Instead of 'heart normal,' document 'heart regular rate and rhythm, no murmurs, rubs, or gallops, normal S1 and S2.' Specific documentation shows what you actually examined and provides baseline for future comparison. Document pertinent positives (abnormal findings) and pertinent negatives (normal findings that help rule out differential diagnoses).
Organize exam systematically by organ system: General/Constitutional, HEENT, Neck, Cardiovascular, Respiratory, Abdomen, Extremities, Skin, Neurological, Psychiatric. You don't need to examine every system for every visit. Focus on systems relevant to chief complaint, but document what you examined. For comprehensive exams, complete multi-system documentation is required. Use consistent format so others can find information quickly. Many physicians use templates with normal findings that they modify when abnormalities exist. This ensures completeness and efficiency.
Remember that physical exam is objective data you observe or measure, not symptoms patient reports (that's ROS/HPI). Document vital signs, inspection findings, palpation results, auscultation findings, special tests performed. Include measurements when relevant (liver span in cm, size of mass in cm, severity of edema 1+ to 4+). Your exam findings should logically connect to your assessment and plan. If you're diagnosing pneumonia, your respiratory exam should be documented. Complete, specific exam documentation supports your clinical thinking and protects you legally.
What You Get
Complete physical exam templates by system
Normal findings as customizable starting point
Proper medical terminology and format
Systematic organization by organ system
Ready to modify with actual patient findings
Professional documentation structure
How It Works
- 1Select organ systemsChoose which systems you examined
- 2AI generates templateCreates PE documentation with normal findings in 1-2 minutes
- 3Customize with actual findingsModify template with your patient's specific exam results
- 4Paste into noteCopy completed physical exam into your documentation
Frequently Asked Questions
Should I document systems I didn't examine?
No, only document systems you actually examined. For focused visits, you might examine only systems relevant to chief complaint. For comprehensive exams, you examine multiple systems. Your documentation should reflect what you actually did. If you examined heart and lungs but not abdomen, document cardiovascular and respiratory systems only. Don't use 'normal' for systems you didn't assess.
How do I document when everything is normal?
Be specific about normal findings. Instead of 'exam normal,' document each system you examined with specific normal findings. Use templates with normal findings you modify when abnormalities exist. Example: 'Respiratory: clear to auscultation bilaterally, no wheezes, rhonchi, or rales, normal respiratory effort.' This shows what you examined and found normal. It's more useful clinically and legally than 'lungs normal.'
What level of detail is appropriate?
Detail should match complexity of visit and clinical situation. For straightforward visits, standard systematic documentation suffices. For complex cases or when specific findings are critical to diagnosis, more detail helps. Always document pertinent positives clearly. Include pertinent negatives that help with differential. If you're ruling out appendicitis, document McBurney's point tenderness, rebound, psoas sign. If you're diagnosing heart failure, document JVP, lung sounds, edema specifically.
Can I use templates with pre-populated normal findings?
Yes, this is efficient and ensures completeness. Many physicians use templates with normal findings for each system, then modify when abnormalities exist. This saves time and ensures you don't forget exam elements. Just make sure you actually performed the exam elements you're documenting. Templates should reflect your actual examination, not serve as fiction of exam you didn't do.
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