[GET] Comprehensive Physical Exam Template
Good turgor. No lesions, nodules or rashes are noted. No onychomycosis. Eyes: Extraocular muscles are intact. Pupils are round and reactive to light. Conjunctivae are pink and moist. Sclerae are white and nonicteric. Nose: Nasal mucosa is pink and...
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ED Charting and Coding: Physical Exam (PE)
There are no crackles, wheezes or rhonchi noted. There is no crepitus on palpation. No murmurs are noted. There are no lifts, heaves or thrills noted on palpation. There are good bowel sounds. There is no rebound or guarding. There is no evidence of hernia. SKIN: There are no rashes, lesions or ulcers noted. Warm and dry with good turgor. There is no clubbing, cyanosis or edema. Sensation to light touch and pain is intact bilaterally. There is no apparent mood disorder. Vital Signs: T: [x] degrees. P: [x] beats per minute. R: [x] breaths per minute. BP: [x] mmHg. Face: No lesions. Eyes: Conjunctiva pink. Sclera are anicteric. EOMs are full. Ears: The right and left ear canals are clear. Both tympanic membranes are intact. Nose: No external or internal nasal deformities. Nasal septum is midline. Mouth: The lips are within normal limits. The dentition is good. Tongue is midline with no lesions. The oral cavity is clear.
Physical exam template
Pharynx: Tonsils are normal size and clear. No exudates. Neck: Supple. No lymphadenopathy. Thyroid: No thyromegaly or masses. Chest: Clear to auscultation and percussion. Heart: Regular sinus rhythm. No gallops or murmurs. Abdomen: Soft, nontender. Normoactive bowel sounds. No organomegaly or masses. Extremities: No cyanosis, edema or deformities. Neurologic: Grossly intact. Skin: No lesions.
Physical Exam Template
Problem Focused—One to five bullets from one or more organ systems. Expanded Problem Focused—At least six bullets from any organ systems. Detailed—At least two bullets from six organ systems or 12 bullets from two or more organ systems. Comprehensive—Two bullets from each of nine organ systems. They range from limited examinations of single body areas to general multisystem or complete single organ system examinations. A notation of abnormal without elaboration is insufficient. DG: Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area s or organ system s should be described. DG: The medical record for a general multisystem examination should include findings about eight or more of the 12 organ systems. The physical examination is just another component of the evaluation and management visit required to communicate among healthcare professionals evidence of patient care, as well as justifying billing for a claim.
Normal Physical Exam Template Samples
Practices are providing patients with quality care, as well as providing information documentation to ensure accurate and timely reimbursement for the services rendered to patients. For more information on simplifying the Medicare and private payer coding guidelines to help ensure accurate reimbursement, contact the ACR coding and auditing specialists at practice rheumatology.
Form FAA 8700-2 - Comprehensive Medical Examination Checklist (BasicMed)
Expanded problem focused exam — a limited exam of the affected body area or organ system and any other symptomatic or related body area s or organ system s. Detailed exam — an extended exam of the affected body area s or organ system s and any other symptomatic or related body area s or organ system s. Comprehensive exam — a general multisystem exam, or a complete exam of a single organ system and other symptomatic or related body area s or organ system s. The guidelines include a detailed chart that specifies the exam elements that must be performed and documented to justify each level of exam. In the chart, the shaded headings list the organ systems and body areas as CPT categorizes them. These body areas and systems are worth some attention. Look closely at the terms and the way they are grouped; they may not correspond exactly to those you are used to running through in your mind. This presumably represents recognition that these systems are easier to ask about than to examine. Now, back to the multisystem exam chart.
Annual Physical Exam Checklist
Parenthetical examples provide clarification and guidance within the chart. Finally, CMS urges you to keep in mind that the use of the documentation guidelines is not a substitute for medical necessity. A well documented service won't automatically be assumed to have been medically necessary.
FREE 9+ Sample Physical Examination Forms in PDF | MS Word
No scleral icterus. Pupils are equal, round, and reactive to light and accommodation. No conjunctival injection is noted. Oropharynx is clear. Mouth revealed good dentition, no lesions. Tympanic membranes are clear. NECK: Supple. Trachea is midline. No evidence of thyroid enlargement. No lymphadenopathy or tenderness. Nontender to palpation. No wheezes, rhonchi, or rales. No murmurs, gallops, or rubs. No skin or nipple retractions. No nipple discharges or masses. No mass, tenderness, guarding, or rebound. No organomegaly or hernia. Bowel sounds are present. No CVA tenderness or flank mass. The phallus is circumcised. There are no penile plaques or genital skin lesions. The glans is normal.
Physical exam of 1995 or 1997?
The meatus is orthotopic, patent, and clear. The testicles are descended bilaterally without masses or tenderness. The epididymis and cords are normal. The perineum is normal. External genitalia normal. Vagina and cervix without lesions or masses. Uterus is normal. Adnexa negative for masses or tenderness. Urethral meatus is normal. Perineum and anus are normal. Normal sphincter tone. No masses. Prostate is smooth and nontender and without nodules or fluctuance. No masses or tenderness. Gait is normal. Deep tendon reflexes are intact. Recent and remote memory is intact. Appropriate mood and affect. SKIN: Warm, dry, and well perfused. Good turgor. No lesions, nodules or rashes are noted. No onychomycosis. Eyes: Extraocular muscles are intact. Pupils are round and reactive to light. Conjunctivae are pink and moist. Sclerae are white and nonicteric. Nose: Nasal mucosa is pink and moist.
Complete Head-to-Toe Physical Assessment Cheat Sheet
Septum is midline. Mouth: Oral mucosa is pink and moist. Dentition is good. There is no jugular venous distention noted. There are no carotid bruits noted. There are no palpable masses. There are no crackles, wheezes or rhonchi noted. There is no crepitus on palpation. No murmurs are noted. There are no lifts, heaves or thrills noted on palpation. There are good bowel sounds. There is no rebound or guarding. There is no evidence of hernia. SKIN: There are no rashes, lesions or ulcers noted. Warm and dry with good turgor. There is no clubbing, cyanosis or edema. Sensation to light touch and pain is intact bilaterally. There is no apparent mood disorder. Vital Signs: T: [x] degrees. P: [x] beats per minute. R: [x] breaths per minute. BP: [x] mmHg. Face: No lesions. Eyes: Conjunctiva pink. Sclera are anicteric. EOMs are full. Ears: The right and left ear canals are clear. Both tympanic membranes are intact. Nose: No external or internal nasal deformities. Nasal septum is midline. Mouth: The lips are within normal limits.
Physical examination
The dentition is good. Tongue is midline with no lesions. The oral cavity is clear. Pharynx: Tonsils are normal size and clear. No exudates. Neck: Supple. No lymphadenopathy. Thyroid: No thyromegaly or masses. Chest: Clear to auscultation and percussion. Heart: Regular sinus rhythm. No gallops or murmurs. Abdomen: Soft, nontender. Normoactive bowel sounds. No organomegaly or masses. Extremities: No cyanosis, edema or deformities. Neurologic: Grossly intact. Skin: No lesions.
How to Document the Physical Exam
He is in no acute distress. He does have an area of purpura over his left periorbital area. There is also a small laceration over his forehead. The sinuses are otherwise nontender. Pupils are equal and reactive. The nares are patent. Oropharynx reveals poor dentition but is clear without lesions. NECK: Supple without lymphadenopathy. No crackles or wheezes are heard. Inguinal area is normal.
Exam Documentation: Charting Within the Guidelines
Skin: Warm and dry without any rash. There is no costovertebral angle tenderness. No evidence of trauma. Ears: No acute purulent discharge. Eyes: Conjunctivae pink with no scleral jaundice. Nose: Normal mucosa and septum. NECK: Supple with no cervical or supraclavicular lymphadenopathy. Trachea is midline. Thyroid: Not palpable. Coarse breath sounds with some rhonchi. No peripheral edema. SKIN: Normal color, turgor and temperature. No ulcerations or rashes noted. No wheezing. No crackles. The patient has a loud systolic ejection murmur. No organomegaly. Normoactive bowel sounds. GCS is Skin: Warm and dry without exanthem.
Normal physical exam documentation
Pupils are equal, round and reactive to light. Extraocular movements are intact. Oral mucosa is moist. There is no obvious bleeding in the gum. Oropharynx is without erythema or exudate. Lungs: Breath sounds are clear bilaterally without rales, rhonchi or wheezing. Heart: No elevation of JVP. Heart is irregularly irregular with no appreciable gallops, rubs, murmurs or extra heart sounds. Abdomen: Soft, nontender, nondistended in all quadrants. No audible bowel sounds. No palpable masses. Extremities: Warm without clubbing, edema or cyanosis.
Normal Physical Examination Template Format For Medical Transcriptionists
Neurological: The patient is oriented to person, place and time. Strength and sensation are grossly intact. Face is symmetric. General: A well-developed, well-nourished male with pleasant affect. Extraocular movements full. Sclerae anicteric. Neck: Supple. Free of masses or thyromegaly. No carotid bruits. Lungs: Clear. Symmetrically expanding. Cardiac: Rhythm is sinus. No murmurs or gallops. Abdomen: Obese, soft with obvious inflammation focused within the right subumbilical area. Scattered healed maculopapular ulcerations are distributed along the subumbilical transverse belt line. Surrounding one of the ulcerations, right infraumbilical region, is significant edema and erythema, which expands in a band-like distribution along the belt line across the right lateral abdomen to the midaxillary line level.
Department of Neurology
Early fluctuance is developing around the epicenter of the inflammation, and there is some minor purulent drainage therefrom. No intraabdominal masses, hepatic or splenic enlargement. No peritoneal signs are present. Neurologic: No focal deficits. Chest is clear. Heart is regular. The right eyelid is closed; she is able to open it. Both pupils are equal, reactive to light and accommodation. There appears to be no overt nystagmus with the exception of perhaps a mild tap on the left and leftward gaze in the left eye. Both TMs and canals are occluded with cerumen. He is alert and oriented x3. Extraocular muscles are intact. Pupils are equal, round, and reactive to light and accommodation. Nares appeared normal. Mouth is well hydrated and without lesions. Mucous membranes are moist. Posterior pharynx clear of any exudate or lesions. NECK: Supple. No lymphadenopathy or thyromegaly. Positive bowel sounds. No hepatosplenomegaly was noted. SKIN: No ulceration or induration present.
Are you using the right physical exam templates?
Temperature Pulse noted to range from as low as 36 beats per minute to above 62 beats per minute. Respiratory rate He was lying in bed comfortably. SKIN: There were fading ecchymotic lesions on thighs and arms. Eyes: Extraocular muscles were intact. The patient was anicteric. Pupils were equally reactive to light. Ears: There were no lesions. Nose: No lesions were noted. Throat: There was no thrush, no exudate, no erythema. There was no evidence of gum bleeding. There was no JVD. No bruit was heard over the carotids. There were slight basilar crackles, left more than right. Bowel sounds were present. There were no masses in the rectum. There was full range of motion in all the extremities. There was no edema.
UC San Diego's Practical Guide to Clinical Medicine
Extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation. External inspection of the ears and nose showed no scars, lesions, or masses. Lips, teeth, and gums showed normal mucosa. The oral mucosa, hard and soft palate, tongue and posterior pharynx were normal. NECK: Supple and symmetric. There was no thyroid enlargement, and no tenderness, or masses were felt. LUNGS: Auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs.
Comprehensive Physical Examination Template Health
The liver span was approximately cm in the right midclavicular line by percussion. The liver edge was nontender. The spleen was not palpable. There were no inguinal or umbilical hernias noted. No ascites was noted. Sphincter tone was normal. There was no external hemorrhoids or rectal masses. Stool Hemoccult was negative. The prostate was normal size without any nodules appreciated men only. There was no tenderness or effusions noted. Muscle strength and tone were normal. Normal affect. Gait was normal. Normal deep tendon reflexes with no pathological reflexes. Sensation to touch was normal.
How to Handle an Unobtainable Exam - For The Record Magazine
All rights reserved. Are you using the right physical exam templates? The main difference between the guidelines lies in the detail that surrounds the appropriate level of documentation for physical examination. I heard from someone attending one of your seminars that systems and body areas have been considered differently in auditing charts for evaluation and management services. Can you explain this further? The guidelines have a specific set of bullet points listed for several specialty examinations. The exams relevant to urology include the multi-system examination and the genitourinary system examination. Both examinations have specific systems and body areas lumped into a prescribed physical examination, with a list of elements for each system or body area. The guidelines require the use of the list of elements listed in the documentation guidelines, with responses indicating whether the examination reveals a normal or abnormal finding and, if abnormal, to provide specific documentation.
Cheat Sheet: Normal Physical Exam Template | ThriveAP
The guidelines for a comprehensive multi-system exam state: Comprehensive examination: Should include at least nine organ systems or body areas. Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border is expected. Continue to next page for more. The guidelines, on the other hand, are not specific. There is no list included in the guidelines providing a check sheet for elements based on systems or body areas. However, the guidelines do include a list of organ systems and body areas as a guide. The list of body areas is as follows: head, including the face chest, including breasts and axillae abdomen.
Physical Examination
Weight can be measured and recorded by ancillary staff. General appearance of patient e. Neck Examination of neck e. Respiratory Assessment of respiratory effort e. Cardiovascular Palpation of heart e. Chest Inspection of breasts e. Gastrointestinal Examination of abdomen with notation of presence of masses or tenderness; Examination of liver and spleen; Examination for presence or absence of hernia; Examination when indicated of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, and rectal masses; and Obtain stool sample for occult blood test when indicated. Minimum requirements not met Upon admission to the hospitalist service, a year-old female presents with uncontrolled diabetes mellitus resulting in hyperglycemia.
General Adult Physical Exams - The SOAPnote Project
The hospitalist performs a complete exam, but documentation only reflects an expanded, problem-focused exam with respect to both the and guidelines. An expanded, problem-focused exam does not satisfy the minimum requirements for initial hospital care see Table 1. Genitourinary Female Pelvic examination with or without specimen collection for smears and cultures , including: Examination of external genitalia e. Lymphatic Palpation of lymph nodes in two or more areas: Neck, axillae, groin, other.
Normal Physical Exam Template – 3
August 28, Documentation serves two very important purposes. First, it keeps you out of jail. Okay, okay, incarceration might not be totally realistic, but there are plenty of scenarios in which your actions as a healthcare provider might be called into question. Documenting your findings on a physical exam as well as the reasoning for your plan of care serves as a defense in the event another provider, patient etc.
Exam Guidelines
Second, documentation helps with continuity of care. Documenting your findings and plan for the patient allows other providers to continue caring for the individual in your absence. Or, it allows for others to provide care in conjunction with yours without interfering with your part of the care plan. Keep everyone in the loop by documenting exam findings and your next steps with the patient. Under pressure to be efficient, most providers abbreviate physical exam documentation to just the necessities.
Incorporating Ultrasound in the Physical Exam Documentation – Resus Review
There is a fine balance between spending too much time on charting and including too little in your documentation. The amount you are paid for each patient encounter is based on your documentation, so cutting corners can directly affect your wallet. In most cases, you do not need to examen and provide documentation for each and every body system. For purposes of a general overview, in this template we will give a down and dirty overview of each body system.
Physical examination - Wikipedia
Finally disclaimer alert! With certain patients, you may need to note findings that are not included in this sample write-up. Are You Ready to Thrive? Learn more about our online residency program; we pair clinical and professional development to take advanced practice providers to the next level. No acute distress. Well developed, hydrated and nourished. Appears stated age. Skin: Skin in warm, dry and intact without rashes or lesions.
General Adult Physical Exams - The SOAPnote Project
Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing. Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed. Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. Fundi appear normal including optic discs and vessels. No signs of nystagmus. Eyelids are normal in appearance without swelling or lesions. Ears: The external ear and ear canal are non-tender and without swelling. The canal is clear without discharge. The tympanic membrane is normal in appearance with normal landmarks and cone of light. Hearing is intact with good acuity to whispered voice.
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