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Physical Exam Template: Normal Findings, Example, and Checklist

The ScribeMD Team ·

You've just finished listening to a patient's lungs. They're clear, the heart sounds normal, and the abdomen is soft. By the time you sit down to chart, the next patient is already in the room, and the exam section is a blank box.

A good physical exam template fixes that: a set of standard normal findings, organized by system, that you edit to match what you actually found. This guide gives you a complete normal physical exam template, a focused exam example with abnormal findings, a head-to-toe assessment checklist, and the rules that keep templated exams honest.

What the physical exam section should do

The exam is the objective part of the note. It records what you saw, heard, and felt, and it should support the assessment that follows. A reader should be able to tell which systems you examined, what was normal, and what wasn't.

That last point matters most. A templated exam that lists systems you didn't examine is inaccurate, and it can cause problems in a chart review or a dispute. The template is a starting point. Your findings are what go in the note.

Normal physical exam template

These are standard normal-finding phrases. Keep the systems you examined and delete the rest.

  • General: Alert, well appearing, in no acute distress. Well nourished and well developed.
  • Vital signs: BP, HR, RR, temperature, SpO2 on room air, weight. Record the actual values.
  • Head: Normocephalic, atraumatic.
  • Eyes: Conjunctivae clear, sclerae anicteric. Pupils equal, round, and reactive to light. Extraocular movements intact.
  • Ears: External ears normal. Canals clear. Tympanic membranes intact with normal landmarks bilaterally.
  • Nose: Nares patent, no discharge.
  • Mouth and throat: Moist mucous membranes. Oropharynx clear, no erythema or exudate.
  • Neck: Supple, full range of motion. No lymphadenopathy. Thyroid not enlarged.
  • Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops. Peripheral pulses intact.
  • Respiratory: Normal effort. Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
  • Abdomen: Soft, non-tender, non-distended. Normal bowel sounds. No masses or organomegaly.
  • Musculoskeletal: Normal range of motion. No joint swelling or deformity.
  • Extremities: No edema, cyanosis, or clubbing.
  • Skin: Warm and dry. No rashes or lesions.
  • Neurological: Alert and oriented to person, place, and time. Cranial nerves II to XII grossly intact. Strength and sensation normal and symmetric. Normal gait.
  • Psychiatric: Normal mood and affect. Behavior appropriate. Judgment and insight intact.

Some exams need specific additions, such as a genitourinary, breast, or rectal exam. Document a chaperone when one is present, and record those findings only when you performed the exam.

Focused physical exam example

Most visits don't need a full head-to-toe exam. Here's a focused exam for an adult with three days of cough and fever, where some findings are abnormal:

  • General: Alert, appears mildly ill, speaking in full sentences, in no respiratory distress.
  • Vital signs: Temp 38.4 °C, HR 98, RR 20, BP 124/78, SpO2 95% on room air.
  • Mouth and throat: Mucous membranes moist. Oropharynx mildly erythematous, no exudate.
  • Neck: Supple. No lymphadenopathy.
  • Cardiovascular: Regular rhythm, mildly tachycardic. No murmurs.
  • Respiratory: Normal effort, no accessory muscle use. Crackles at the right lung base. Increased tactile fremitus at the right base. No wheezes. Left lung clear.
  • Extremities: No edema or calf tenderness.
  • Skin: Warm, no rash.

Notice what this example does. The abnormal findings are specific: which side, which area, what you heard. The systems examined match the complaint. The normal findings that matter for the differential, like no calf tenderness, are stated. Systems that weren't examined aren't listed.

The findings then feed the assessment. The patient's story belongs in the history of present illness, and symptoms the patient reports belong in the review of systems, not the exam.

Head-to-toe assessment checklist

For admissions, annual physicals, and nursing assessments, a head-to-toe checklist keeps you from skipping a system. Work top to bottom:

  1. General survey: level of consciousness, distress, appearance, hygiene, body habitus.
  2. Vital signs and pain: full set, plus pain score and location.
  3. Head and face: symmetry, scalp, tenderness, lesions.
  4. Eyes: pupils, movements, conjunctivae, vision if relevant.
  5. Ears, nose, mouth, throat: canals, membranes, nares, mucosa, dentition, oropharynx.
  6. Neck: range of motion, lymph nodes, thyroid, trachea midline, jugular venous distension.
  7. Chest and lungs: effort, symmetry, breath sounds in all fields.
  8. Heart: rate, rhythm, heart sounds, murmurs.
  9. Abdomen: inspect, auscultate, then palpate. Tenderness, distension, masses.
  10. Genitourinary: when indicated, with consent and a chaperone as appropriate.
  11. Musculoskeletal: range of motion, strength, joint swelling, deformity.
  12. Extremities and circulation: pulses, capillary refill, edema, color, temperature.
  13. Skin: color, temperature, turgor, wounds, pressure areas, rashes.
  14. Neurological: orientation, speech, cranial nerves, sensation, coordination, gait.
  15. Psychiatric: mood, affect, behavior, thought content as relevant.

Rules for using a physical exam template

Only document what you examined

This is the big one. If you didn't look in the ears, delete the ear line. A templated normal finding for a system you didn't examine is a false statement in the chart.

Replace normals with specifics

When something is abnormal, write what you found, where, and how much. "Crackles at the right base" is useful. "Abnormal lung exam" isn't.

Watch copy-forward

Carrying last visit's exam into today's note is fast and risky. Check each line against what you found today.

Match the exam to the complaint

A sprained ankle doesn't need a full neuro exam, but it does need neurovascular status of the foot. Focus on the systems that support or rule out your differential.

Where an AI scribe helps, and where it doesn't

An ambient AI scribe listens to the visit, with the patient's consent, and drafts the note. It hears what you say, not what you see or feel. If you palpate the abdomen in silence, the scribe can't record the finding.

Many clinicians handle this by saying findings out loud as they go: "Lungs clear on the left, crackles at the right base." That also tells the patient what you're finding. With ScribeMD, those findings show up in the exam section of a draft note in under 30 seconds. You still review every line, delete anything you didn't examine, and sign. Expect a few weeks of adjusting before narrating the exam feels natural.

To see how a narrated exam turns into a structured draft, book a demo of ScribeMD.