Physical exam documentation examples, a reusable physical exam template, normal and abnormal findings, focused exam formats, and a head-to-toe assessment example.
Physical exam documentation records the objective findings a clinician observes, measures, or elicits during a patient examination. It communicates the patient’s current condition, supports clinical reasoning, and shows what was actually assessed during the encounter. A physical exam may be focused on one complaint or organized as a comprehensive head-to-toe assessment. In either case, the documentation should be specific, relevant, and limited to findings that were actually examined.
Physical exam documentation is the written record of objective findings gathered through direct examination of a patient. These findings commonly appear in the objective section of a SOAP note because they are observed, measured, or elicited by the clinician.
Subjective: Patient reports sharp right knee pain when climbing stairs. Objective: Right knee flexion limited to 110 degrees by pain. Medial joint-line tenderness present. Mild antalgic gait observed.
A physical exam should include the systems and findings relevant to the encounter. The note should show what was examined rather than relying only on broad conclusions.
Example demonstrating more specific documentation versus a vague statement:
Vague documentation: Musculoskeletal exam normal. More specific documentation: No visible swelling or deformity of the right knee. Active flexion to 120 degrees with full extension. No joint-line tenderness. Strength 5/5 with knee flexion and extension.
These terms should not be used interchangeably. Only findings that were actually assessed should be documented as normal or negative. "Unable to assess" should be used when an examination could not be completed, with a reason documented.
A focused physical exam evaluates the body regions and systems most relevant to a specific complaint. A comprehensive physical exam or head-to-toe assessment covers multiple body systems and is commonly used in nursing, admissions, and baseline assessments. The scope of the exam should match the chief complaint, the patient's condition, the clinician's role and scope, the care setting, and organizational documentation requirements.
Not every encounter requires a comprehensive exam. The exam scope should be appropriate to the situation.
The following is a general multisystem outpatient exam example. Use only when the listed systems were actually examined.
General: Alert, cooperative, and in no acute distress. Well appearing and appropriately groomed. Vital Signs: Blood pressure 124/78 mmHg, heart rate 72 bpm, respiratory rate 16 breaths per minute, temperature 36.8°C, oxygen saturation 98% on room air. HEENT: Head normocephalic and atraumatic. Pupils equal, round, and reactive to light. Extraocular movements intact. Oral mucosa moist. Neck: Supple. No cervical lymphadenopathy or visible thyromegaly. Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No audible murmur. Peripheral pulses 2+ and symmetric. Respiratory: Breathing unlabored. Lungs clear to auscultation bilaterally. No wheezes, crackles, or rhonchi. Abdomen: Soft, nondistended, and nontender. Bowel sounds present. No guarding or rebound tenderness. Musculoskeletal: Moves all extremities without apparent difficulty. No visible joint swelling. Strength 5/5 in tested upper- and lower-extremity muscle groups. Neurological: Alert and oriented to person, place, and time. Speech clear. Sensation grossly intact. Gait steady. Skin: Warm and dry. No visible rash on exposed areas.
Examples of concise focused exams for different systems.
Respiratory example: General: Alert and speaking in full sentences. Mildly increased work of breathing. Respiratory: Respiratory rate 22 breaths per minute. Symmetric chest expansion. Expiratory wheezes present bilaterally, greater at the bases. No crackles. Oxygen saturation 94% on room air.
Abdominal example: Abdomen: Soft and nondistended. Mild tenderness to palpation in the right lower quadrant. No guarding or rebound tenderness. Bowel sounds present. No palpable mass.
Musculoskeletal example: Right Knee: Mild swelling without erythema. Tenderness over the medial joint line. Active flexion to 110 degrees, limited by pain. Full extension. Strength 5/5 with flexion and extension. No gross instability with varus or valgus stress. Gait mildly antalgic.
Neurological example: Neurological: Alert and oriented. Speech fluent. Facial movements symmetric. Upper- and lower-extremity strength 5/5 bilaterally. Sensation intact to light touch. Finger-to-nose testing normal. Gait steady.
Skin example: Skin: Three-centimeter area of erythema over the left anterior lower leg. Area warm and mildly tender to palpation. No visible drainage, fluctuance, or open wound.
Use the template below as a prompt. Remove any section that was not assessed.
Normal documentation records assessed systems without identified abnormalities. Avoid using the phrase "normal physical exam" as a substitute for specific findings or as an implication that all systems were examined.
General: Alert, well appearing, and in no acute distress. HEENT: Head normocephalic and atraumatic. Pupils equal and reactive. Oral mucosa moist. Cardiovascular: Regular rate and rhythm. No audible murmur. Peripheral pulses symmetric. Respiratory: Normal respiratory effort. Lungs clear to auscultation bilaterally. Abdomen: Soft, nondistended, and nontender. No guarding or rebound tenderness. Musculoskeletal: No visible swelling or deformity. Full active range of motion in the examined joints. Neurological: Alert and oriented. Strength 5/5 in tested muscle groups. Sensation intact to light touch. Gait steady. Skin: Warm, dry, and intact on examined areas.
Abnormal findings should describe location, laterality, severity, measurements, and functional effects when relevant. Include relevant negative findings and separate raw findings from diagnostic interpretation.
Document location and laterality: Vague: Ankle swollen. Specific: Moderate swelling over the left lateral ankle, greatest around the lateral malleolus.
Include measurements: Vague: Shoulder movement reduced. Specific: Active right shoulder abduction limited to 90 degrees by pain. Passive abduction to 130 degrees.
Describe functional effects: Vague: Abnormal gait. Specific: Antalgic gait with reduced stance time on the right. Patient uses a cane in the left hand.
Separate findings from diagnosis: Physical exam finding: Fine resting tremor of both hands, greater on the right. Assessment: Resting tremor requiring further evaluation.
A general nursing-format head-to-toe assessment example. Sequence and required fields may differ by care setting.
General Survey: Patient awake, alert, and resting comfortably in bed. Speech clear. No acute distress observed. Neurological: Oriented to person, place, time, and situation. Pupils equal and reactive. Hand grips equal. Lower-extremity strength equal bilaterally. Sensation intact to light touch. HEENT: Head atraumatic. Oral mucosa moist. No visible facial asymmetry. Respiratory: Breathing even and unlabored. Chest expansion symmetric. Breath sounds clear bilaterally. Cardiovascular: Regular rate and rhythm. Radial and pedal pulses 2+ bilaterally. Capillary refill under two seconds. No lower-extremity edema. Abdomen: Soft, nondistended, and nontender. Bowel sounds present in all quadrants. Genitourinary: Voiding without reported difficulty. Additional assessment completed as clinically indicated. Musculoskeletal: Moves all extremities. Range of motion grossly intact. Gait steady with standby assistance. Skin: Skin warm and dry. No visible pressure injury. Dressing to left forearm clean, dry, and intact. Lines, Drains, and Devices: Peripheral IV in right forearm. Site clean and without visible redness or swelling. Safety: Bed in low position. Call bell within reach. Fall precautions maintained.
Example limitation: Lumbar flexion not assessed because the patient reported severe pain when attempting to stand.
Review of systems: Patient denies shortness of breath. Physical exam: Breathing unlabored. Lungs clear to auscultation bilaterally.
High-quality physical exam documentation shows what was examined and what the clinician found. A template can improve consistency but should never replace clinical judgment or clinician review.
Whether the exam is focused, comprehensive, or head-to-toe, the final documentation should accurately reflect the current encounter.
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