Quickly Charting a Normal Physical Exam: A Guide for Doctors

What should you include in a normal physical exam note?

When you're documenting a normal physical exam, there are standard sections you should always cover. These include:

• General Appearance: Note if the patient appears well-groomed and comfortable.
• Vital Signs: Record temperature, pulse, respiration rate, and blood pressure. Mention if they're within normal limits (WNL).
• HEENT: Head, eyes, ears, nose, and throat should be noted as normal if there are no issues.
• Neck: Check for normal range of motion and absence of lymphadenopathy.
• Cardiovascular: Heart sounds should be regular, no murmurs or gallops.
• Respiratory: Lungs should be clear to auscultation bilaterally.
• Abdomen: Soft, non-tender, with normal bowel sounds.
• Musculoskeletal: Normal gait and full range of motion.
• Neurological: Alert and oriented, normal reflexes.
• Skin: Warm, dry, and intact.

How can templates help speed up charting?

Using templates can save you a lot of time. Most electronic health records (EHR) systems come with built-in templates. These allow you to quickly select normal findings with just a few clicks. You can also create custom templates that fit your practice style. This way, you're not starting from scratch each time.

Are there shortcuts or abbreviations that can help?

Yes, using standard abbreviations can make your charting faster. Here are some common ones:

• WNL: Within Normal Limits
• RRR: Regular Rate and Rhythm (for heart sounds)
• CTA: Clear to Auscultation (for lung sounds)
• A&O x3: Alert and Oriented to person, place, and time

Be sure your abbreviations are understood by anyone who might read your notes, including other healthcare providers.

What's a practical example of a normal physical exam note?

Here's a sample note for a normal physical exam:

"Patient is a well-nourished, well-developed 45-year-old female in no acute distress. Vital signs stable. HEENT: Normocephalic, atraumatic, PERRLA, EOMI, TMs clear. Neck: Supple, no lymphadenopathy. Cardiovascular: RRR, no murmurs. Respiratory: CTA bilaterally. Abdomen: Soft, non-tender, BS present. Musculoskeletal: Full ROM, no deformities. Neurological: A&O x3, CN II-XII intact. Skin: Warm, dry, intact."

How can practice improve your speed?

The more you practice, the faster you'll get. Familiarizing yourself with common terms and the layout of your EHR system can significantly reduce charting time. Consider setting aside time to practice using templates and shortcuts when you're not in a time crunch.

What if you need to make a quick note during a busy day?

In busy settings, jot down quick notes during the exam and flesh them out later. Use voice recognition software if available to quickly dictate your findings. This can be a huge time-saver.