A head-to-toe adult physical exam formatted for EHR charting (Epic / Cerner / Meditech) — copy-paste row by row, with room for laterality, side, and a one-line impression.
One paragraph before the formal exam starts — interaction, apparent distress, nutritional status, and anything you noticed walking in.
HR, RR, BP (with arm and position), temp, SpO2 on room air. Call out any abnormality against the patient’s baseline.
Head, eyes (pupils, sclera, conjunctiva), ears, nose, throat, neck. Document laterality when relevant so coding pulls it forward.
Lymph nodes, thyroid, JVP/carotid bruits as the picture calls for. Tracheal deviation only when relevant.
Rate, rhythm, murmurs/gallops/rubs, peripheral pulses, edema. Note the auscultation sites in your mental order so the chart reads the same.
Inspection, palpation, percussion, auscultation. Specify wheezes/crackles by location and whether they clear with cough.
Inspection → auscultation → percussion → palpation. Document tenderness, guarding, rebound, organomegaly, and the hernia exam.
Inspect, palpate, range-of-motion, strength. Specify the joint and laterality. Note deformity or effusion when present.
Color, turgor, rash (morphology + distribution), wounds/incisions. The EHR pulls morphology into the dermatology cross-reference, so be specific.
Mental status, cranial nerves, motor, sensory, reflexes, gait. For altered patients, document the GCS components as numbers, not a single sentence.
Mood, affect, thought process, insight, judgment. Note suicidality screen only when the chief complaint or exam calls for it.
A one-paragraph summary signed-off before the MDM. Anchors the EHR’s problem list and the coder’s chart review.
These are working templates — drafts, not legal advice. Verify against your group's local protocol and the most recent society guideline before signing.