[GET] Normal Physical Exam Template
He transfers from the right to the left and the left to the right. Reaches both upper extremities overhead. He has good head and trunk control. He is able to sit unsupported when placed in that position on the exam table with his hips and knees flexed. No clonus was appreciated. PHYSICAL EXAM: MSE: The patient presents as usual with ponytail pulled back behind her head to the mid level of her back, dark and large-framed glasses, minimal amount of make-up, quiet, not always talkative, but when she talks, her speech is goal directed without evidence of thought disorder.
Files related to Normal Physical Exam Template
ED Charting and Coding: Physical Exam (PE)
No organomegaly or mass. No pulsatile masses or bruits. No rales. No murmur. Height 5 feet and 4 inches. Ears and nose externally normal. Pharynx normal. No carotid bruit, no thyromegaly, no adenopathy. Surgical scar present in the neck. Breath sounds normal bilaterally. S1 and S2 normal. No gallop, murmur or rub. Normal bowel sounds. No bruit. No palpable aortic aneurysm, mass or organomegaly.
Cheat Sheet: Normal Physical Exam Template
Moderately obese. No cyanosis, clubbing, or edema. Cranial nerves intact. Balance, gait and coordination normal. Normal affect. SKIN: No significant skin lesions or rashes. She is alert and interactive and answers questions appropriately. She does not appear to be in any discomfort. Sclerae are white. Conjunctivae are pink. Extraocular eye movements are intact and nonpainful. Mucous membranes are moist and pink. NECK: Supple without jugular venous distention or lymphadenopathy. There are no wheezes, rales or rhonchi, and she has good air entry throughout. There were no murmurs, rubs or gallops. There is no rebound or guarding. There are no peripheral extremity clubbing, cyanosis or edema. SKIN: No rashes and is warm and dry with capillary refill time of 2 seconds. She has a normal strength, gait, and balance. The remainder of the breast is soft. In the left upper outer quadrant, there is overlying erythema and tenderness to palpation.
Normal Physical Examination Template Format For Medical Transcriptionists
There is no fluctuance indicative of abscess. There is no bloody discharge expressible from her nipple. The overlying erythema is also warm to the touch but not indurated. Extraocular motions intact. Pupils are equal, round and reactive to light. Mucous membranes are moist. Oropharynx is clear. No rales, rhonchi or wheezes. SKIN: Warm and dry. No focal deficits. Anterior fontanelle was open and flat.
Normal Physical Exam Findings Template (Page 1)
Normocephalic and atraumatic. Positive red reflex in the eyes. Ears were normally set. No cleft lip. No cleft palate. There were no masses in the neck. The chest was symmetrical and clear to auscultation bilaterally. There were no murmurs, rubs or gallop in the heart. Abdomen was soft, nontender, nondistended. No masses and normal female genitalia with no hip clicks. On the back, there were no hair tufts or dimples. NECK: Full range of motion with no meningeal signs. No masses or organomegaly. The patella is medial and nonballotable. He does have some tenderness with patella ballottement.
Physical examination template
There is no femoral tendon pain and the patella does track medially. No tenderness medially or laterally. No tenderness posteriorly. No posterior fossa mass.
Physical Exam Template – Adult (12 years and Older)
The following discussion tries to unravel some of these twisted regulations and will provide tips and tricks on how to improve your physical exam documentation for coding and billing. We are a crooked and perverse generation. Overall, is too vague, is too specific, and the responsibility to choose one or the other falls on your coding department. The guidelines identify Body Areas and Organ Systems as a framework for documenting the physical exam, but do not say what to chart under either. The guidelines define mandatory physical exam elements and called them Bullets. A comprehensive exam requires all bulleted items to be examined, and at least 2 per system to be documented. The full list of bullets is in the appendix at the end of this post.
Department of Neurology
These guidelines also describe Single Organ System examinations, which focus on a primary organ system but require bullets from other systems. Work Smarter, Not Harder: Resuscitating the Physical Exam Develop a structured, comprehensive exam that you can perform on nearly any patient, and use the normal findings for this exam as your documentation template. If your department uses the guidelines, read through the bullets and pick 2 per system to include in your exam. Your examination is part of your decision making. The chief complaint will indicate certain positive or negative findings to be documented.
Physical Exam Template – Children 2 to 11 years
With many EMRs, vital signs are usually automatically pulled into your note. In addition to reviewing all vitals as part of good patient care, include a statement in your documentation that the recorded vital signs were reviewed. ENMT: Atraumatic external nose and ears [1]. Moist MM [2]. RESP: Unlabored respiratory effort [1]. Clear to auscultation bilaterally CTAB [2]. No cyanosis or clubbing [3] Skin: Warm, Dry [1]. No rashes or lesions [2]. Sensation grossly intact [2]. Appropriate mood and affect [2]. The 10 listed items are for both the and guidelines. The bracketed red numbers are the bullets for the guidelines. Find out which guidelines your coders use: the list of organ systems is mostly the same, but the rules require far more specific information.
Physical Exam Normal Medical Template Transcription Samples
From an ethical and medical legal perspective, if you document it, examine it! Tailor your smart phrases or macros to a list of normals you reliably perform on every patient, every time, and include placeholders for you to add patient-specific information. If your department utilizes scribes or incorporates medical student notes , take an extra second to review their documentation for completeness and accuracy.
Normal Physical Exam Template Samples
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.
Breast Examination documentation examples
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. The meatus is orthotopic, patent, and clear. The testicles are descended bilaterally without masses or tenderness.
Physical exam template
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.
- (Medical Transcription Sample Report)
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. 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.
epic physical exam template
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. 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.
Cheat Sheet: Normal Physical Exam Template | ThriveAP
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.
General Adult Physical Exams - The SOAPnote Project
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.
Cheat Sheet: Normal Physical Exam Template | MidlevelU | Physics, Exam, Body systems
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. 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.
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