Best Practices for Documenting Normal Physical Exam Findings from Observation
One-click templates and macros to generate findings from a normal physical examination are acceptable time-saving functions as long as the final, signed documentation accurately reflects what occurred during the patient-physician encounter. 1
Standardized Documentation Approaches
The nature of medical documentation—other than the patient narrative—tends to be controlled and standardized with respect to documenting normal or expected findings, as evidenced by examination of paper-based records from most physicians. 1
Templates, drop-down boxes, and macros are common documentation tools that can improve efficiency but must be used appropriately to avoid misrepresentation of the medical necessity requirement. 1
Clinical documentation is best served by brevity and thoughtfulness, efficiently conveying findings, thought processes, decisions, and actions taken. 1
Appropriate Use of Documentation Tools
When using one-click templates for normal physical exam findings, ensure they replicate what would otherwise be handwritten in paper-based records. 1
Shortcuts to bring forward history from previous encounters are acceptable if verified and updated by the physician as necessary for appropriate documentation. 1
Document the quality of imaging/examination performed (optimal, fair, suboptimal, or poor) as this affects the reliability of findings and potential need for additional testing. 1
Avoiding Common Pitfalls
The Centers for Medicare & Medicaid Services (CMS) considers documentation "cloned" when each entry in the medical record is worded exactly like or similar to previous entries, which can be considered misrepresentation. 1
Excessive use of drop-down lists, check boxes, and templates can be distracting and disruptive to vital clinical thinking and can standardize away the unique aspects of each patient encounter. 1
Documentation tools should not force physicians to enter information in ways inconsistent with medical training or typical diagnostic approaches. 1, 2
Key Components of Physical Exam Documentation
For normal physical exam findings, standardized terminology should be used consistently rather than forced uniqueness. 1
When documenting pulse intensity, it should be recorded numerically as: 0 (absent), 1 (diminished), 2 (normal), or 3 (bounding). 1
Include relevant negative findings that are clinically significant for the patient's presentation, rather than including boilerplate negative findings solely to satisfy guidelines. 2
Documentation in Electronic Health Records
EHRs should facilitate hybrid documentation by allowing physicians to efficiently capture the patient narrative and supplement it with context-sensitive, template-driven data. 1
When using EHR tools, indicate the source of pulled data and supplement with appropriate narrative content to maintain documentation integrity. 2
Consider implementing links to the sources of referenced data to provide attribution and the ability to trace information to the original author. 1
Ensuring Accurate Billing and Compliance
Documentation should focus primarily on supporting patient care and improving clinical outcomes, rather than simply meeting billing requirements. 2
When using time as the determining factor for E&M coding, document total time spent, including non-face-to-face work on the same day. 2
Provider education and feedback systems can significantly improve coding accuracy and documentation quality. 2
Special Considerations for Specific Examinations
For breast examinations, document thorough examination of tissue in the upper outer quadrant and under the areola/nipple as these are the two most common sites for cancer. 1
For cardiovascular examinations, document normal findings using standardized terminology while ensuring the final documentation accurately reflects the actual examination performed. 1
For physical examinations in general, the goal is to obtain valid information concerning the health of the patient while identifying, analyzing, and synthesizing the accumulated information into a comprehensive assessment. 3, 4