Physical Exam Documentation Builder
Generate comprehensive physical examination documentation. Select normal or abnormal findings for each system and copy the formatted note.
General/Constitutional
HEENT
Neck
Cardiovascular
Respiratory
Abdomen
Musculoskeletal
Skin
Neurological
Psychiatric
Generated Physical Exam
Select findings above to generate physical exam documentation.
Documentation Tips
- Click "Apply Normal Template" for a quick complete normal exam
- Toggle abnormal findings and select specific abnormalities
- Use "N/E" for systems not examined in focused exams
- Add custom notes for specific details not in the options
Physical Examination Documentation Guide
Comprehensive vs. Focused Exams
A comprehensive physical exam documents findings across all organ systems and is typically performed during annual wellness visits, initial evaluations, or hospital admissions. A focused exam concentrates on the systems relevant to the patient's chief complaint.
System-by-System Documentation
- General: Overall appearance, nutritional status, and level of distress
- HEENT: Head, eyes, ears, nose, and throat examination
- Cardiovascular: Heart sounds, rhythm, pulses, and peripheral circulation
- Respiratory: Breath sounds, respiratory effort, and chest examination
- Abdominal: Inspection, auscultation, palpation findings
- Neurological: Mental status, cranial nerves, motor, sensory, reflexes
E/M Documentation Requirements
For Evaluation and Management coding, physical exam documentation contributes to the level of service. While the 2021 E/M guidelines focus on medical decision-making, thorough physical exam documentation remains essential for clinical care and medical-legal purposes.
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