Documentation of Normal HEENT Physical Examination Findings
A normal HEENT examination should be documented systematically by anatomical region, explicitly stating "normal" or "within normal limits" for each component rather than using vague terms like "unremarkable."
Structured Documentation Framework
The documentation should follow a standardized anatomical sequence to ensure completeness and facilitate comparison across examinations 1:
Head
- Normocephalic, atraumatic
- No visible deformities, masses, or lesions
- Scalp intact without tenderness 1
Eyes
- Pupils equal, round, and reactive to light and accommodation (PERRLA)
- Extraocular movements intact in all directions
- Conjunctivae clear without injection or discharge
- Sclerae anicteric
- No periorbital edema or discoloration
- Red reflex present bilaterally and symmetric 2, 3
- No anisocoria (pupil size difference <1mm is physiologic) 2, 3
Critical caveat: Always document pupil size in millimeters and assess in both bright and dim lighting, as anisocoria >1mm warrants further investigation 2, 3. The red reflex examination is essential in pediatric patients to exclude serious pathology 4.
Ears
- External ears normal in size, shape, and position
- Ear canals patent without erythema, discharge, or foreign bodies
- Tympanic membranes intact, pearly gray, with normal light reflex
- Landmarks clearly visible
- No tenderness to palpation of tragus or mastoid 1
Nose
- Nares patent bilaterally
- Nasal mucosa pink and moist without edema, pallor, or erythema
- Nasal septum midline without deviation, perforation, or spurs
- No nasal discharge or crusting
- No tenderness over sinuses to palpation 1
Important distinction: Document whether the osteomeatal complex appears patent on examination, as mucosal thickening with patent ostium has different clinical implications than obstruction 1.
Oral Cavity and Throat
- Lips and buccal mucosa pink and moist
- Dentition intact without caries or malocclusion
- Gingiva pink without inflammation or bleeding
- Tongue midline, normal size and mobility, without coating or lesions
- Hard and soft palate intact without lesions
- Oropharynx without erythema, exudate, or lesions
- Tonsils present (or absent if previously removed), normal size without erythema or exudate
- Uvula midline
- Posterior pharynx without cobblestoning or postnasal drainage 1, 5
Neck
- Supple without masses or lymphadenopathy
- Thyroid normal size, smooth, non-tender, moves with swallowing
- No jugular venous distension
- Trachea midline
- Full range of motion without pain 1
Documentation Pitfalls to Avoid
Never use non-specific terms like "HEENT normal" or "HEENT unremarkable" without documenting individual components 1. This approach:
- Fails to demonstrate that a complete examination was performed
- Provides no baseline for future comparison
- May have medicolegal implications if pathology is later discovered
Age-specific considerations: In pediatric patients, explicitly document the red reflex examination findings, as absence or asymmetry requires immediate ophthalmologic referral to exclude retinoblastoma and other vision-threatening conditions 4. In elderly patients, note that pupils measuring 2-3mm in dim lighting represent normal age-related miosis 3.
Standardization improves quality: Using consistent terminology and anatomical sequence across all examinations facilitates accurate communication between providers and enables meaningful comparison of serial examinations 1. The examination should be sufficiently detailed that another clinician could understand exactly what was assessed and found 1.