How should normal skin findings be documented in the physical examination note?

Documentation of Normal Skin Findings in Physical Examination Notes

When documenting normal skin findings, report that the skin examination was performed and describe it as "normal" or "negative," without the need for extensive descriptive detail when no abnormalities are present. 1

Standard Documentation Framework

For Normal Findings

• State explicitly that a skin examination was performed and document the result as "normal," "unremarkable," or "no abnormalities detected" 1

• The physical examination note should confirm that the skin was visually inspected, but extensive description of normal characteristics is unnecessary when findings are benign 1

• For comprehensive examinations (such as melanoma surveillance or HIV care), document that a "complete" or "full-body" skin examination was performed, including all skin surfaces 1, 2

Essential Elements to Include

• Document the extent of examination: Specify whether you performed a focused examination of one area versus a complete skin examination of all body surfaces 1, 2

• For complete skin examinations, note that you examined:

  • All skin surfaces including scalp 2
  • Special attention areas when relevant (e.g., sun-exposed areas, intertriginous zones) 1
  • Mucous membranes when indicated by clinical context 1

• Use standardized terminology such as "skin: normal" or "skin: no rashes, lesions, or masses noted" rather than creating varied descriptive phrases 1

When to Expand Documentation

Document Specific Normal Findings When Clinically Relevant

• In high-risk populations (e.g., patients on immunotherapy, HIV-infected patients, melanoma surveillance), explicitly state the absence of specific concerning findings 1, 2:

  • "No suspicious pigmented lesions"
  • "No evidence of seborrheic dermatitis, Kaposi sarcoma, or fungal infections" 1
  • "No rash, blistering, or erythema" 1

• For pediatric examinations, document normal skin color, perfusion, and absence of rashes or lesions as part of the comprehensive assessment 3

• When examining patients with cancer or on systemic therapies, note the absence of treatment-related skin changes 1

Common Pitfalls to Avoid

• Do not omit documentation of the skin examination entirely—this creates medicolegal risk and suggests an incomplete physical examination 1, 4

• Avoid overly detailed descriptions of normal anatomy (e.g., "skin is smooth, soft, warm, dry, intact with normal turgor")—this adds documentation burden without clinical value 1

• Do not use inconsistent terminology across examinations—develop a standardized format for your practice 1

• For complete skin examinations, do not document only the presenting area—explicitly state that distant sites were examined, as this has been shown to detect occult malignancies in 0.6-3.3% of patients 4

Practical Documentation Examples

Brief Normal Documentation

• "Skin: Normal examination, no lesions"
• "Skin: Unremarkable, no rashes or masses"
• "Complete skin examination performed: normal" 1

Expanded Normal Documentation (High-Risk Contexts)

• "Complete skin examination including scalp performed. No suspicious pigmented lesions, no evidence of secondary melanoma" 2
• "Skin examination: No rash, no evidence of seborrheic dermatitis, Kaposi sarcoma, or fungal infection" 1
• "Full body skin examination: No bullae, erosions, or erythema. No evidence of immune-related adverse events" 1