Say what you find.
Speak during the exam or dictate afterward.
Physical exam documentation. Your findings, organized.
Turn spoken examination findings into a structured note. Keep the body system, laterality, and relevant detail together in one editable note.
No credit card required. 10 free actions every month.
Examine. Describe. Document.
Your observations lead. The documentation follows.
Give each finding a place.
Bring the details into your preferred structure.
Make the note yours.
Adjust the wording and add details in one place.
Physical exam findings. Organized by system.
Explore a few examples. Select a system to see spoken findings become a clear note.
“Alert, comfortable, and in no acute distress.”
General appearance
Alert and comfortable. No acute distress.
“Heart rhythm is regular. No murmur heard.”
Cardiovascular
Regular rhythm. No murmur auscultated.
“Lungs are clear on both sides. Breathing is unlabored.”
Respiratory
Lungs clear to auscultation bilaterally. Respiratory effort unlabored.
“Abdomen is soft and non-tender.”
Abdominal
Abdomen soft and non-tender to palpation.
“Right shoulder has reduced active abduction due to pain.”
Musculoskeletal
Right shoulder: active abduction limited by pain.
“Alert and oriented to person, place, and time. Gait is steady.”
Neurological
Alert and oriented to person, place, and time. Steady gait.
A focused exam. Or a broader view.
See how the details carry from spoken findings into a structured note.
A focused shoulder exam
Spoken findings
“Right shoulder: no swelling. Active abduction to 90 degrees, limited by pain. Passive range of motion is preserved.”
- Right shoulder
- 90° abduction
- Pain-limited
Physical exam note
- Inspection
- Right shoulder without swelling.
- Active movement
- Abduction to 90°, limited by pain.
- Passive movement
- Passive range of motion preserved.
Side, measured movement, and limitation stay together.
A system-by-system exam
Spoken findings
“Alert and comfortable. Heart rhythm regular, no murmur heard. Lungs clear on both sides. Abdomen soft and non-tender.”
- General
- Heart & lungs
- Abdomen
Physical exam note
- General
- Alert and comfortable.
- Cardiovascular
- Regular rhythm. No murmur auscultated.
- Respiratory
- Lungs clear to auscultation bilaterally.
- Abdominal
- Abdomen soft and non-tender to palpation.
Each recorded finding sits under its body system.
Office visit note
- SOAP note
- H&P
- Custom template
S
Subjective
O
Objective · Physical examination
General Alert and comfortable. No acute distress.
Cardiovascular Regular rhythm. No murmur auscultated.
Respiratory Lungs clear to auscultation bilaterally.
A
Assessment
P
Plan
Your exam, within the full clinical picture.
A focused exam. A complete picture.
Keep exam findings where they belong: alongside the history, assessment, and plan.
- SOAP and history & physical notes
- Focused or system-by-system exams
- Custom templates for your workflow
Good questions. Clear answers.
How do I capture physical exam findings?
Say your findings aloud during the encounter, or dictate them afterward. Vero organizes the details into an editable examination section.
Can I use my own examination template?
Yes. Use a custom template to organize findings by body system, or include the exam within a SOAP or history and physical note.
Can I edit the physical exam note?
Yes. Add findings, adjust the wording, and arrange the sections to match the way you document.
Does this work for focused examinations?
Yes. Document the systems and findings relevant to the visit, whether you are recording a focused shoulder exam or a broader physical examination.
Give the exam your attention. Give the note a head start.
Start with the findings from your next encounter.
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No credit card required. Start with the free plan.