Normal Physical Exam Template

A flexible and practical Normal Physical Exam Template that improves your patients' examinations.

By Ericka Pingol on May 15, 2024.

Fact Checked by RJ Gumban.

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What is a normal physical examination?

A normal physical examination is a comprehensive healthcare professional evaluation of a patient's overall health status. It involves various clinical methods to assess the body systems and gather objective data to determine possible concerns.

Physical examinations are an essential part of medical care. They provide healthcare providers with crucial information about the patient's general appearance, vital signs, and the functioning of various body systems. This information, combined with the patient's history, helps guide the diagnosis and treatment process (Bickley, 2021).

Printable Normal Physical Exam Templates

Download these Normal Physical Exam Templates to improve your physical examination progress and your client's treatment journey.

Components of a physical examination

A thorough physical examination typically includes the following components:

General appearance physical examination

The General Appearance Physical Examination begins with observing the patient's general appearance, including observed posture, mobility aids, if any, motor function, and even visual acuity. These initial observations can provide a health care professional with insights into a patient's health status and potential problems.

Elements such as poor hygiene, abnormal gait, or unusual affect might signal underlying conditions that require further investigation.

Assessing vital signs and patient’s history

Taking vital signs — such as heart rate, respiratory rate, and blood pressure—is a fundamental step in the physical exam process. These measurements offer critical data reflecting the functioning of the patient's body systems.

Integrating patient history information with current examination findings enables healthcare providers to create a more holistic understanding of the patient's health and guide the diagnostic process.

Examination of body systems

A thorough examination covers various body systems, assessing for normal function and any signs of disease or illness. This includes:

  • Respiratory system: Absence of distress, normal breath sounds without wheezes, and the use of accessory muscles are signs of healthy lung function. Respiratory distress or abnormal breath sounds may indicate infections or conditions like asthma.
  • Cardiovascular system: The heart is examined for heart rate, rhythm, and the absence of abnormal sounds. An apical pulse at the midclavicular line and normal capillary refill are significant signs of a functional cardiovascular system.
  • Gastrointestinal system: Health assessments look for normal bowel sounds, absence of palpable masses, or signs indicating bowel obstruction. Documenting bowel sounds and abdominal pain is critical in evaluating the gastrointestinal tract's health.
  • Musculoskeletal and neurological systems: Evaluating normal gait, posture, and mobility without needing mobility aids can provide insights into the patient’s motor function and potential neurological concerns. Normal muscle strength and joint stability are indicators of musculoskeletal health.

How to do a physical exam documentation

Effective physical exam (PE) documentation is critical for healthcare providers. It ensures clear communication and continuity of care, providing a valuable record for future reference (Swartz, 2021). It can be helpful to consider the following:

  1. The initial portion of your documentation should paint a general picture of the patient's health status:
    • General appearance: Describe the patient's posture (comfortable, slumped), use of mobility aids (cane, walker), and overall hygiene. Note any signs of distress, such as respiratory trouble or pain.
    • Affect and mood: Document the patient's emotional state (calm, anxious, depressed). This can provide clues about potential underlying issues.
  1. Following the initial observations, systematically document your findings for each body system examined.
  2. Document both normal and abnormal findings. A clear picture of a patient's baseline health includes knowing what's functioning normally.
  3. Use objective terms. Avoid subjective statements like "good" or "bad." Instead, describe findings in clear, observable terms (e.g., "non-tender," "normal capillary refill").

To make physical assessment documentation more efficient, a healthcare provider can use tools such as a complete physical exam template. This can help them create documentation with a more structured approach.

What is a Normal Physical Exam Template?

While there's no single "one-size-fits-all" template for a normal physical exam (PE), a framework can significantly improve efficiency and ensure consistent documentation. It serves as a standardized framework to ensure that all important information and essential components of the assessment are covered and valuable information is recorded accurately.

A typical physical exam template includes the following sections:

  1. Patient information: This section captures the patient's demographic details, such as name, age, gender, and the reason for the examination.
  2. General appearance: When assessing general appearance, physical exam documentation includes notes about a patient's overall appearance, including posture, hygiene, and any signs of distress or discomfort.
  3. Vital signs: This section records the patient's temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation.
  4. Head and neck examination: This involves evaluating the head, face, eyes, ears, nose, mouth, throat, and neck for abnormalities.
  5. Respiratory system: Assessment of respiratory rate, breath sounds, and signs of respiratory distress or accessory muscle use.
  6. Cardiovascular system: Examination of the apical pulse, heart sounds, and peripheral pulses.
  7. Abdominal examination: Inspection, auscultation, and palpation of the abdomen for masses, tenderness, bowel sounds, and organomegaly.
  8. Musculoskeletal system: Observation of gait and range of motion and assessment for swelling, deformities, or tenderness in joints and muscles.
  9. Neurological assessment: Evaluation of mental status through speech and perception, cranial nerves, motor function, sensory function, and reflexes.
  10. Skin examination: Inspection of the skin for rashes, lesions, discoloration, or other abnormalities.
  11. Additional assessments: Space for documenting further examinations, such as pelvic or rectal examinations, if applicable.
  12. Assessment and plan: This section summarises the overall assessment and outlines the following steps, such as ordering additional tests, making a diagnosis, or recommending treatment or follow-up care.

How to use this physical examination template

Our template is functional and easy to use. A printable physical exam template is available on this page to help you quickly understand and make the most out of this tool in your practice. Follow a few steps below to get yourself started with this template:

Step 1: Download the template

You can download the complete physical exam template for free onto your devices or access it from the Carepatron template library. This gives you more flexibility in terms of the template design and content.

Step 2: Patient information & vitals

Document the necessary patient information for identification purposes. Then, record all the vitals on the template for a quick assessment of the patient's primary health status.

Step 3: Review the system

We have listed many systems for you. This doesn't mean you need to assess all of them, only those relevant to the patient's presentation. Select and comment on all the reviewed systems, and mark those not examined as ‘not examined.'

Step 4: Additional notes

You can practically write down anything in this section, from essential documentation of patients' presenting complaints to highly specialized areas of examination that are not included in the worksheet. Essentially, you are adding anything that brings a holistic picture of the patient to anyone who will view this examination result in the future. 

Step 5: Documentation

Once everything is recorded appropriately, you should store this document organized and securely. Due to the confidentiality of the patient and the importance of the information within this document, please treat it with care and professionalism.

Benefits of using this template

Using a well-designed physical exam template offers several advantages:

  • Consistency: It promotes consistency in the examination process, ensuring that healthcare providers follow a standardized approach and do not overlook any crucial aspects of the assessment.
  • Completeness: A comprehensive template covers all relevant body systems and examination components, minimizing the risk of omitting important information.
  • Documentation: The template provides a structured format for documenting findings, facilitating clear communication among healthcare professionals, and enabling effective monitoring of a patient's condition over time.
  • Efficiency: Following a predetermined outline streamlines and optimizes the examination process, saving healthcare providers valuable time.

Why use Carepatron as your Normal Physical Exam software?

Carepatron is an excellent choice when it comes to managing physical exams. It is designed to be a comprehensive practice management system for healthcare providers.

Carepatron is built to streamline clinical workflows, including appointment scheduling, patient communication, and documentation. With physical exam templates integrated into our clinical documentation software, you can efficiently record findings, minimizing errors often associated with manual data entry.

Patient privacy and data security are our priority. Carepatron ensures that all patient information, including physical exam results, is stored securely in compliance with healthcare regulations. You can trust that patient data remains confidential, and access to these records is granted only to authorized individuals.

Cut down the administrative burden and focus more on providing care. Choose Carepatron and sign up today!

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References

Bickley, L. (2021). Bate’s guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Swartz, M. H. (2021). Textbook of physical diagnosis: History and examination. Elsevier - Health Science.

How do you document general appearance?
How do you document general appearance?

Commonly asked questions

How do you document general appearance?

To document a patient's general appearance, note their apparent state of health, level of consciousness, signs of distress or discomfort, posture and mobility, hygiene, and any assistive devices used. Remark on the patient’s level of alertness, orientation (time, place, person), skin condition, and overall demeanor.

What is included in a general physical exam?

A comprehensive general physical examination typically covers several critical assessments to evaluate the patient's overall health status. This includes measuring and documenting vital signs, such as temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation. The examination also involves thoroughly evaluating the head and neck, respiratory system, cardiovascular system, abdomen, musculoskeletal system, neurological function, and skin inspection.

What are the normal findings in physical assessment?

Normal findings in a physical assessment can vary slightly among individuals, but there are generally accepted ranges and observations that indicate good health. Vital signs are expected to fall within normal ranges specific to the individual's age, gender, and overall condition.

In the musculoskeletal assessment, normal findings include full range of motion in all joints, absence of deformities or swelling, and no tenderness upon palpation. The neurological examination should demonstrate intact neurological function, appropriate mental status, and normal reflexes. Finally, a healthy skin color and appearance, without any concerning lesions or rashes, are considered normal findings during the skin inspection.

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