Best Practices for Documenting Normal Physical Exam Findings

Standardized Documentation Approaches

The American College of Physicians recommends that one-click templates and macros to generate findings from a normal physical examination are acceptable time-saving functions as long as the final, signed documentation accurately reflects what occurred during the patient-physician encounter 1, 2
The nature of medical documentation tends to be controlled and standardized with respect to documenting normal or expected findings, as evidenced by examination of paper-based records from most physicians, according to the American College of Physicians 3, 1
Templates, drop-down boxes, and macros are common documentation tools that can improve efficiency but must be used appropriately to avoid misrepresentation of the medical necessity requirement, as stated by the American College of Physicians 1, 4
Clinical documentation is best served by brevity and thoughtfulness, efficiently conveying findings, thought processes, decisions, and actions taken, according to the American College of Physicians 2

When using one-click templates for normal physical exam findings, ensure they replicate what would otherwise be handwritten in paper-based records, as recommended by the American College of Physicians 3, 2
Shortcuts to bring forward history from previous encounters are acceptable if verified and updated by the physician as necessary for appropriate documentation, according to the American College of Physicians 1, 4
Document the quality of imaging/examination performed (optimal, fair, suboptimal, or poor) as this affects the reliability of findings and potential need for additional testing, as stated by the European Society of Cardiology 5

The Centers for Medicare & Medicaid Services considers documentation "cloned" when each entry in the medical record is worded exactly like or similar to previous entries, which can be considered misrepresentation, according to the American College of Physicians 1, 2
Excessive use of drop-down lists, check boxes, and templates can be distracting and disruptive to vital clinical thinking and can standardize away the unique aspects of each patient encounter, as warned by the American College of Physicians 1, 4

For normal physical exam findings, standardized terminology should be used consistently rather than forced uniqueness, as recommended by the American College of Physicians 1, 2
When documenting pulse intensity, it should be recorded numerically as: 0 (absent), 1 (diminished), 2 (normal), or 3 (bounding), according to the American Heart Association 7

For breast examinations, document thorough examination of tissue in the upper outer quadrant and under the areola/nipple as these are the two most common sites for cancer, as recommended by the American Cancer Society 8
For cardiovascular examinations, document normal findings using standardized terminology while ensuring the final documentation accurately reflects the actual examination performed, according to the European Society of Cardiology and the American Heart Association 5, 7