A physical exam template lists each body system with the usual normal findings already written, so you keep what was normal, replace what wasn’t, and delete what you didn’t examine. Copy the free template, see a complete normal exam and a focused exam with abnormal findings, and check what to write for each system.
Blank physical exam template
FreePHYSICAL EXAMINATION Patient: [Name, age] Date and time: [Date, time] Examiner: [Name, credentials] Type of exam: [Complete, or focused on the presenting problem] Reason for exam: [New patient, pre-employment, symptom, or follow-up] VITAL SIGNS Blood pressure: [Reading in mmHg, arm and position, repeated after rest if high] Heart rate: [Beats per minute, regular] Respiratory rate: [Breaths per minute, counted] Temperature: [Reading and route] Oxygen saturation: [Percent on room air, or on oxygen with device and flow] Height, weight, and BMI: [Measurements, when taken] Pain: [Score out of 10 and site, or none] GENERAL APPEARANCE [Well appearing, alert, in no acute distress. Well nourished and well groomed.] SKIN [Warm and dry. Normal color, no pallor, jaundice, or cyanosis. No rash, lesions, or bruising.] HEAD AND EYES Head: [Normocephalic, atraumatic.] Eyes: [Conjunctivae clear, sclerae anicteric. Pupils equal, round, and reactive to light. Extraocular movements full.] Visual acuity: [Right and left eye, corrected or uncorrected, when tested] EARS, NOSE, AND THROAT Ears: [External ears normal. Canals clear. Tympanic membranes intact and pearly gray.] Hearing: [Whispered voice heard in both ears, when tested] Nose: [Mucosa pink, no discharge. Septum midline.] Mouth and throat: [Mucous membranes moist. Dentition in good repair. Pharynx without redness or exudate. Tonsils not enlarged.] NECK AND LYMPH NODES Neck: [Supple, full range of motion. Trachea midline. Thyroid not enlarged, no nodules.] Lymph nodes: [No cervical or supraclavicular lymphadenopathy.] CARDIOVASCULAR Heart: [Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops.] Pulses: [Radial and dorsalis pedis pulses 2+ and equal on both sides.] Edema and neck veins: [No peripheral edema. No jugular venous distension.] RESPIRATORY Inspection: [Breathing unlabored, no accessory muscle use. Chest expands equally.] Auscultation: [Clear to auscultation on both sides. No wheezes, crackles, or rhonchi.] Percussion: [Resonant throughout.] ABDOMEN Inspection: [Flat, no scars, distension, or hernias.] Auscultation: [Normal bowel sounds.] Percussion: [Tympanic, no shifting dullness.] Palpation: [Soft, non-tender. No guarding or rebound. No masses. Liver and spleen not enlarged.] Flanks: [No costovertebral angle tenderness.] MUSCULOSKELETAL Joints: [Full range of motion of all major joints. No swelling, redness, deformity, or tenderness.] Spine: [Normal curvature. No midline tenderness. Full range of motion.] NEUROLOGICAL Mental status: [Alert and oriented to person, place, and time.] Cranial nerves: [II to XII intact.] Motor: [Normal bulk and tone. Strength 5/5 in all four limbs.] Sensation: [Intact to light touch in all four limbs.] Reflexes: [2+ and symmetric at biceps, triceps, knees, and ankles. Plantar responses flexor.] Coordination and gait: [Finger-to-nose normal. Gait steady. Romberg negative.] PSYCHIATRIC [Calm and cooperative. Mood and affect normal. Speech normal in rate and volume. Thought process logical. Insight and judgment intact.] BREAST, GENITOURINARY, AND RECTAL, WHEN INDICATED Consent and chaperone: [Consent given. Chaperone offered: name and role, or declined by the patient] Breast: [Symmetric. No masses, skin changes, or nipple discharge. No axillary lymphadenopathy.] Genitourinary: [Normal external genitalia. No lesions, discharge, or hernia.] Rectal: [Normal sphincter tone. No masses or tenderness.] FINDINGS AND IMPRESSION Abnormal findings: [Each one by system: what you saw, felt, or heard, with side, site, size, and grade] Not examined: [Systems not examined, and why] Impression: [Normal examination, or what the findings suggest] Next steps: [Tests, treatment, referral, or follow-up the findings lead to] Signed: [Examiner name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Occupational health clinic, pre-employment exam
31-year-old woman starting as a warehouse associate: lifting up to 50 lb, 10-hour shifts on her feet, and forklift driving after training. Complete exam. BP 118/76, left arm, seated; HR 66, regular; RR 14; T 36.6 °C (97.9 °F), oral; SpO2 99% on room air. Height 168 cm (66 in), weight 70 kg (154 lb), BMI 24.8. No pain.
Well appearing, alert, in no distress. Well nourished and well groomed. Skin warm and dry, normal color. Tattoo on the left forearm. Two small, well-healed scars on the right knee from an arthroscopy at 19. No rash or lesions of concern.
Normocephalic, atraumatic. Conjunctivae clear, sclerae anicteric. Pupils equal, round, and reactive to light; eye movements full. Visual acuity 20/20 right, 20/25 left, uncorrected, on a Snellen chart. Ear canals clear; tympanic membranes intact and pearly gray. Whispered voice heard in both ears. Nose and throat normal; dentition in good repair. Neck supple; thyroid not enlarged; no cervical or supraclavicular lymph nodes.
Regular rate and rhythm; normal S1 and S2; no murmurs, rubs, or gallops. Radial and dorsalis pedis pulses 2+ and equal on both sides. No edema. Breathing unlabored; clear to auscultation on both sides.
Flat, no scars. Normal bowel sounds. Soft, non-tender; no masses; liver and spleen not enlarged. No umbilical or inguinal hernia with coughing. No costovertebral angle tenderness.
Spine: normal curvature, no tenderness, full flexion, extension, and rotation. Shoulders, elbows, wrists, hips, and ankles: full range of motion, no swelling or tenderness. Right knee: no effusion, full range of motion, ligaments stable, no joint-line tenderness; same as the left. Squats fully and rises without support.
Alert and oriented to person, place, and time. Cranial nerves II to XII intact. Strength 5/5 in all four limbs. Sensation intact to light touch. Reflexes 2+ and symmetric. Gait steady; heel, toe, and tandem walking normal; Romberg negative. Calm and cooperative; mood and affect normal; speech normal; thought process logical.
Not examined: not part of a pre-employment exam, no symptoms, and not requested.
Abnormal findings: none. Old right knee arthroscopy, with a normal knee exam today. Not examined: breast, genitourinary, and rectal, as above. Impression: normal complete examination, with no findings that limit the duties in her job description. Next steps: employer form completed as fit for the role with no restrictions; the exam details stay in the clinic record.
Emergency department, acute visit
27-year-old man with 18 hours of pain that started around the navel and moved to the right lower abdomen; nausea, no appetite, vomited once. Focused exam. T 38.1 °C (100.6 °F), oral; HR 104, regular; BP 128/76, right arm, lying; RR 18; SpO2 98% on room air. Pain 7/10 in the right lower abdomen, worse with walking and with bumps on the drive in.
Uncomfortable. Lies still on his back with the right hip flexed; winces when the stretcher is moved. Walked in slowly, bent forward. Skin warm, dry, and flushed. No jaundice. No rash or blisters over the right flank or abdomen.
Tachycardic, regular rhythm; normal S1 and S2; no murmurs. Breathing unlabored. Clear on both sides, including the right base; no crackles or dullness.
Flat, no scars or hernias. Bowel sounds present but reduced. Tender at McBurney’s point, with voluntary guarding and rebound tenderness in the right lower quadrant. Pain in the right lower quadrant when coughing. Rovsing sign positive: pressure in the left lower quadrant causes pain on the right. Psoas sign positive on the right; obturator sign negative. Upper abdomen and left side not tender. No masses. Liver and spleen not enlarged. No costovertebral angle tenderness on either side.
Exam explained and consent given; chaperone offered and declined. External genitalia normal. Both testes descended, normal lie, not swollen or tender; cremasteric reflex present on both sides. No inguinal hernia.
Abnormal findings: temperature 38.1 °C; heart rate 104; tenderness at McBurney’s point with guarding and rebound; positive Rovsing and psoas signs. Normal: lungs, testes, flanks, and upper abdomen. Not examined: rectal, which would not change the plan; head and neck, joints, and a full neurological exam, not relevant today. Impression: fever with localized right lower quadrant peritoneal signs, most consistent with acute appendicitis. Next steps: nothing by mouth; IV fluids and pain relief; CBC, CRP, electrolytes, creatinine, and urinalysis; CT of the abdomen and pelvis with IV contrast; general surgery consulted at 14:20.
The numbers that show how unwell the patient is, before a word of the exam.
Avoid: A respiratory rate of 16 written from habit. Count it: a fast breathing rate is often the first abnormal sign in pneumonia and sepsis.
How the patient looks at a glance, then the skin you see during the exam.
Avoid: “No acute distress” for a patient lying still, knees drawn up. Say what you saw.
Eyes, ears, nose, mouth, and throat, then the thyroid, trachea, and lymph nodes. Add visual acuity and hearing when the visit needs them.
Avoid: “PERRLA” when you didn’t test accommodation. Most exams test light only; write “pupils equal and reactive to light.”
Heart and lungs, with each added sound described so the next examiner can compare.
Avoid: “Murmur present.” Without grade, timing, and site, no one can tell if it changed.
Look, listen, percuss, then feel, starting away from the pain.
Avoid: “Abdomen benign.” Write where it was tender, or that it wasn’t, and what you felt.
The joints and spine you examined, each compared with the other side.
Avoid: “Full range of motion of all joints” after watching the patient walk in. Name the joints you moved.
Mental status, cranial nerves, strength, sensation, reflexes, and gait, then mood, affect, and thinking.
Avoid: “Neuro grossly intact.” Say what you tested, so a later change can be compared.
Sensitive exams, done only when symptoms, screening, or the visit call for them.
Avoid: A normal genitourinary or rectal line that came with the template. If you didn’t examine it, the record must not say you did.
The abnormal findings in one place, what you skipped, and what it all means.
Avoid: “Exam unremarkable” in the summary when an abnormal finding sits above it.
A macro or copied note fills every system with normal findings, including ones you never examined. The record then says something that didn’t happen. Auditors look for identical exams across visits. Delete each system you didn’t examine.
“Abdomen soft, non-tender” left in the template above an impression of appendicitis makes the whole note hard to trust. Read every line against your impression before you sign.
Focused doesn’t mean one system. For right lower quadrant pain, check the lungs, testes, flanks, and skin too: pneumonia, torsion, a kidney stone, and shingles can all cause pain there.
“Lesion on back” or “crackles” can’t be followed up. Give the side, site, size, and grade, so the next examiner can tell whether it changed.
“Within normal limits” doesn’t say what you checked, and readers joke that it means “we never looked.” Write the finding itself, such as “lungs clear on both sides.”
Vero Scribe drafts the exam in your template from the visit, with the patient’s consent, or from your dictation, system by system. You review and edit every section, delete any system you didn’t examine, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Start with the vital signs and general appearance, then go system by system in the same order every time. For each system you examined, keep the normal wording if it was normal, or replace it with what you found, with side, site, size, and grade. List the systems you didn’t examine. End with an impression that links the findings to the reason for the visit.
A typical normal adult exam reads: well appearing, in no acute distress. Skin warm and dry, no rash. Pupils equal and reactive to light. Tympanic membranes clear, pharynx not red. Neck supple, no lymphadenopathy. Heart regular rate and rhythm, no murmurs. Lungs clear on both sides. Abdomen soft, non-tender, non-distended. No edema. Alert and oriented, strength and sensation normal, gait steady. Mood and affect normal. Use each line only for a system you examined.
A complete exam covers every system, for a new patient, an admission, a pre-employment exam, or a preventive visit. A focused exam covers the systems related to the complaint and the ones that could explain it, for acute and follow-up visits. For a cough with fever, that means vital signs, general appearance, ears and throat, neck nodes, heart, and lungs.
Yes, if you edit it every time. Keep the normal wording only for the systems you examined and found normal, replace it where you found something, and delete the rest. A macro or a note copied from the last visit that fills in systems you didn’t examine makes a false record.
NAD (no acute distress), PERRL (pupils equal, round, reactive to light), EOMI (extraocular movements intact), RRR (regular rate and rhythm), CTAB (clear to auscultation bilaterally), NTND (non-tender, non-distended), and A&O ×3 (alert and oriented to person, place, and time). Use only the ones your organization accepts, and avoid WNL.
Both go system by system. A head-to-toe assessment is the nursing assessment done each shift, with risk scores, lines and drains, and escalation. A physical exam is the diagnostic exam a physician, nurse practitioner, or physician assistant does, with special tests and an impression.
Yes. Copy it, or download it as a Word or text file. No account needed.
Capacity for one decision at one time: the information given, the four abilities in the patient’s words, the finding, and who decides next.
The clinician’s assessment after a positive screen: ideation, intent, means, the formulation, and the plan.
Falls history, gait and balance tests, orthostatic BP, medication review, and a plan matched to the risk.
The full pre-op assessment before noncardiac surgery: history, capacity, RCRI, airway, medication plan, and a clear recommendation.
After a job offer: the job’s demands, relevant history, immunizations, vision and hearing, a job-focused exam and tests, and a fit outcome without the diagnosis.
Say your findings as you examine; Vero sorts them by body system for your review.
New patient visits, physicals, and acute visits, drafted from the conversation.
Record vital signs with units, times, and oxygen, and show the trend.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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