How do I properly document a physical exam?

Properly Documenting a Physical Examination

A comprehensive physical examination documentation should include vital signs, general appearance, and systematic examination of each body system with specific findings recorded in a clear, organized format that supports patient care and improves clinical outcomes through enhanced communication.

Essential Components of Physical Examination Documentation

Patient Identification and Demographics

• Patient name, medical record number, date of birth, sex
• Date and time of examination
• Reason for examination/chief complaint
• For children: age to one decimal place (e.g., 6.3 years) 1

Vital Signs

• Blood pressure (measured in both arms when appropriate)
• Heart rate (recorded numerically: 0-absent, 1-diminished, 2-normal, 3-bounding) 1
• Respiratory rate
• Temperature
• Oxygen saturation (when indicated)
• Height and weight
• BMI calculation when appropriate

General Appearance

• Level of distress
• State of consciousness
• Nutritional status
• Posture and gait
• Obvious physical abnormalities
• For cardiovascular assessment: note cyanosis, pallor, dyspnea during conversation 1

Systematic Body Examination

Document each system examined with specific positive and negative findings:

Head, Eyes, Ears, Nose, and Throat

• Head: shape, symmetry, tenderness
• Eyes: visual acuity, pupillary responses, extraocular movements
• Ears: external examination, tympanic membranes
• Nose: patency, discharge, septum
• Throat: mucosa, tonsils, dentition

Neck

• Range of motion
• Thyroid examination
• Lymphadenopathy
• Jugular venous pressure and pulsations 1
• Carotid pulse contour and bruits 1

Cardiovascular

• Heart sounds (S1, S2, presence of S3/S4)
• Murmurs (location, radiation, intensity, timing)
• Point of maximal impulse
• Precordial palpation findings 1

Respiratory

• Respiratory effort
• Chest expansion
• Percussion notes
• Breath sounds
• Adventitious sounds (wheezes, crackles, rubs)

Abdominal

• Inspection (distension, scars)
• Auscultation (bowel sounds, bruits) 1
• Palpation (tenderness, masses, organomegaly)
• Percussion (tympany, dullness)

Musculoskeletal

• Range of motion of major joints
• Muscle strength (graded 0-5)
• Muscle tone
• Gait assessment when relevant

Neurological

• Mental status
• Cranial nerves
• Motor function
• Sensory function
• Reflexes
• Coordination

Vascular

• Pulse examination at all peripheral sites (brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, posterior tibial) 1
• Allen's test when hand perfusion assessment is needed 1
• Skin color, temperature, and integrity of extremities 1
• Presence of edema

Skin

• Color, texture, turgor
• Rashes, lesions
• Distal hair loss, trophic changes (when relevant) 1

Documentation Format Best Practices

Structure and Organization

• Use clear headings for each body system
• Organize findings in a consistent, logical sequence
• Use standardized terminology
• Avoid vague terms (e.g., "hymen not intact") 1
• Document both positive and pertinent negative findings

Efficiency Tools

• When appropriate, use templates and macros for standardized elements like review of systems 1
• For previously documented information that remains accurate, use "review/edit and/or attest, and then copy/forward" technique 1
• Capture structured data only where useful for care delivery or essential for quality reporting 1

Avoiding Common Pitfalls

1. Avoid value judgments or interpretations of patient's body language 1
2. Never use templates without customizing to the specific patient encounter
3. Don't document findings you didn't actually assess
4. Avoid copying forward information without verifying its current accuracy
5. Don't use abbreviations that could be misinterpreted

Special Considerations for Specific Examinations

Cardiovascular Assessment

• Document presence/absence of jugular venous distention
• Note hepatojugular reflux when assessing volume status 1
• Record presence of peripheral edema in context of other findings 1

Vascular Examination

• Document pulse intensity using numerical scale (0-3) 1
• Note any bruits over major vessels 1
• Document skin changes in extremities (color, temperature, hair distribution) 1

Pediatric Examination

• Modify electrode placement for ECG as needed for breast tissue in adolescents 1
• Document growth parameters with appropriate percentiles
• Note developmental milestones when relevant

Sexual Assault Examination

• Use precise, objective terminology
• Document exact descriptions rather than interpretations 1
• Maintain proper chain of evidence when applicable 1

Final Documentation Checklist

• All required elements included
• Findings described clearly and objectively
• Pertinent positive and negative findings documented
• Appropriate use of templates/macros with personalization
• Documentation supports medical decision-making
• No inappropriate copying from previous notes

Remember that the primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication 1, not merely to satisfy billing requirements.