Hello again!
I wanted to post this awhile ago but couldn’t figure out the best way to present it. So I’m hoping to be able to lay this out in a relatively easy way for you to follow and understand. And hopefully, help fill you in where you feel you are lacking.
In all honesty, I probably won’t be able to do all that. But hey, I’ll try!
The systems:
The PE, or physical exam, is broken into systems just like the ROS is. The PE is much more detailed than the ROS, as you can have an infinite amount of exam findings. Plus, the ROS is just to discuss symptoms of the patient. But the PE is to describe what the physician actually finds. This goes into the objective portion of the chart.
Systems include:
- General Appearance
- Head
- Eyes
- ENT
- Neck
- Cardiac
- Lungs
- Abdomen
- Genitourinary
- Rectal
- Breast
- Musculoskeletal
- Back (sometimes just lumped in with MSK)
- Extremities (sometimes just lumped in with MSK)
- Skin
- Psych
- Lymph
Now there may be some different categories depending on the EMR being used. Additionally, different specialities will use different categories, or selective categories for what benefits or fits into that specialty.
For example, a cardiologist may only use General, Neck, Cardiac, Lungs, and Extremities in majority of their notes, and then add more if needed. But for Family Practice or Internal Medicine, they will use several of the above. Typically a full exam will have 12 systems that are evaluated.
The other thing you need to remember, is a well visit or first patient encounter for general medicine will have more systems that are needed to be examined than a brief return visit for a problem focused exam.
I really wish I could remember how many bullet points were needed for problem focused versus detailed exams. I think it is 9 and 18, but don’t quote me on that.
Touch versus no-touch exams:
No-touch exams are a way for medical providers to use other senses such as sight, smell, and hearing, (things outside of touch) to add observations about a patient’s current health state.
They fill out the chart to help with both a better picture of how the patient is doing at the time of evaluation and eventually for billing. But doctors mainly use it to include a more rounded picture of how the patient was during presentation. Billing is more of a hospital/clinic thing and/or a scribe may be required to keep track of those things.
Examples of this include: Alert, able to converse without difficulty, slurring speech, garbled speech, smells of alcohol, breath smells fruity, face symmetric, head normocephalic and atraumatic, normal respirations/no respiratory distress, no acute distress, moves all extremities without difficulty, able to move (i.e. arm or neck) with some ROM (range of motion) during conversation, good color, no overt skin rash noted, etc.
You get my point. These are all things that you can see/smell/hear, usually within a few seconds of walking into a room with a patient.
A touch exam is what you would typically think of when a PE is done. It is more in depth and includes things like listening to heart and lungs, palpating the abdomen, doing ROM tests for extremities, and doing a more thorough skin exam.
The breakdown:
There will usually be an additional place on the PE to note that vital signs were checked. It’s a really bad thing if the vitals aren’t entered into the chart OR weren’t reviewed by the provider. In every case of seeing a patient, physicians/nurses/PA’s all check the vital signs. Whether they mention it or not. This is a checkbox that serves to say they did check it, even though everyone does…
If your provider does not check it with every patient you have bigger problems my dear.
General Appearance: This is the first part of every PE. It serves to set a general picture of the patient. Is it good? Is it bad? Do they look relatively normal and healthy?
You get my point.
What sort of things are found under this system? Things to include are mostly observations. A lot of this can be obtained when you first walk into a room and you see a patient either in the chair, on the exam table, in the hospital bed, or walking around the room. It helps illustrate if a patient is sick, in distress, or doing just fine.
Head: This section of the chart is usually pretty small. Unless of course there is a head trauma. This section will usually always have normocephalic & atraumatic checked. Again, unless there is a head trauma. In which you would describe any changes or trauma noted to the head (as a whole) and face.
Eyes: Normally you would find things like PERRL and EOMI checked for most patients. But basically you are putting the appearance of the eyes here (if normal or abnormal) and the findings if a specialized eye exam is done.
ENT: This includes everything ears, nose, and throat. External appearances, and a closer inspection of each area of the head.
Neck: Mainly if they can move it. So does it look supple? (Basically can it move without difficulty). Is there restricted ROM? Why is there restricted ROM? This may also have external appearance and potentially lymph gets added in here too.
Lymph: You have lymph everywhere. The major areas of lymph nodes include the face, neck, supraclavicular/axillary area, and groin. But you literally have these suckers everywhere. Majority of the time you may just use note if they do or don’t have cervical lymphadenopathy, which can be lumped under neck. Other times you will have a more in-depth exam finding or evaluation.
Cardiac: Everything to do with the heart. You can also place anything pertaining to the cardiovascular system, including pulses, warmth, color, etc.
Lungs: Everything to do with the lungs. This is usually just an auscultation exam. But may also include things like appearance of chest, tenderness of the chest wall, and any speciality tests. If the additional are added, then it would fall under “chest” heading.
Abdomen: Full abdominal exam/findings. May include kidneys/flank area as well. Same thing applies: appearance, percussion, auscultation, and tenderness.
GU/rectal: This is not typically done on most patients. For obvious reasons. Nobody likes their nether-regions being examined unless they have an issue OR it is a general well exam that needs to be done for health screening purposes. Because it is not normally included, you will likely have to add this section to your chart. (Unless you work in a gynecology or prostate clinic).
Breast: Same thing, this is not normally an exam that is done. Except if you work in a women’s clinic or gynecology clinic or unless it is a maintenance exam/screening exam or they have a specific complaint. You will likely need to add this into the PE section.
Musculoskeletal (will include back and extremities here): There is a lot you can put here. ROM (range of motion), warmth/cool to touch, pulses, how does the skin look? Strength, reflexes, sensation. All of that.
Skin: Usually you will just put intact, of good color or something like that UNLESS neither of those are true. Things like rashes are the biggest thing that you put under skin. You can also put isolated trauma injuries here such as lacerations, burns, etc.
Psych: This will not be done in every case either. Things like depression screenings, if someone is anxious, if their affect is off, paranoid, delusional, hallucinating, all that fun stuff. Unless of course you work the psych unit in the ER or are working in a psychiatry office.
But you will figure out with each exam what your provider you work with likes in each section/their specifics for their exam. This is just a general guide.
Example PE (normal):
I got this example from https://www.soapnote.org/general/general-adult-physical-exams/ and added a few things. Your templates will vary greatly depending on who you work with and what specialty you are in. These are just examples. Honestly, they go a little too in-depth for some of these if you ask me...
GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress.
HEAD: normocephalic. Atraumatic.
EYES: PERRL, EOMI. Fundi normal, vision is grossly intact.
- To be honest I’m pretty sure you need to do an evaluation with an ophthalmoscope for fundoscopic findings, so should not be included in every exam…
EARS: External auditory canals and tympanic membranes clear, hearing grossly intact.
NOSE: No nasal discharge. External nasal appearance appears symmetric. Turbinates pink, moist, non-boggy.
THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. Mallampati score of (1- 5/5).
NECK: Neck supple, non-tender without lymphadenopathy, masses, or thyromegaly.
CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. RRR (regular rhythm and rate). There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits.
- Carotid bruits can also go under neck.
- Cap refill can go under skin as well.
- Extremity findings can also go under MSK or extremity (if this is a specified section on the exam).
LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. Normal appearing chest. No chest tenderness.
ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses.
- You may also see this as S/NT/ND, but this is not always an approved abbreviation.
MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait.
- Gait can also go under neurological exam.
BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm.
- See the similarity here with the MSK exam? Most of the time this is included in MSK.
EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities.
- Remember, some of this can be part of the cardiovascular exam but you see it in the extremities. Other findings are just MSK related. This is usually under MSK.
LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity.
- Okay honestly, I feel like the website I’m getting this information from is beating a dead horse. BUT, you can see again that you can move findings to different areas of the chart.
NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal.
- YOU MUST write the cranial nerves (CN) in Roman numerals. If there is an issue with a cranial nerve, you can write “CN II-XII intact except for CN III” or whichever CN is the issue.
- Reflexes can go under extremities as well. Same with sensation.
SKIN: Skin normal color, texture and turgor with no lesions or eruptions.
PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal.
I want to remind you all that if aspects of the chart are not actually evaluated/examined DESPITE being in your providers "normal template" you need to take it out. No touch findings/evaluations can usually be left in unless they are contradictory. In general, if something is abnormal or contradictory to what is in your general template you need to change it to the correct exam findings.
Dictation:
Okay. You will receive the PE in one of three ways.
- You will be dictated to in the room while the exam is occurring. As a new scribe (or if your provider is just particular AF) you will receive all the normal and abnormal findings. If you are a more advanced scribe you will likely just receive the abnormal findings.
- You will be dictated to in their office or a dictation room where several providers hang out between patients. Same thing applies as above.
- You are an experienced scribe and they just assume you know what you are doing. They may give you just the abnormal findings. They may completely forget that you are a scribe and you didn’t actually do the exam yourself, and you may have to prompt them for abnormal findings.
Since you are being dictated to, you will need to improve your listening and typing skills as a scribe. This is critical! You will also need to make sure you have a good shorthand so you can go back and rewrite/properly add in the examination. As a scribe (especially a new one) you haven’t quite grasped what is normal and abnormal yet. So make sure you are getting all the details so you can accurately put this information in the chart.
Once you have all the information, make sure you are removing contradictory elements in your PE. I can’t stress that enough. I have seen countless scribes forget to remove the contradictory information. If you aren’t sure about something, Ask!
Common Words/Abbreviations:
I will put some common words/abbreviations here. There are a lot. So much so that universities will try to convince you to take a medical terminology course.
Don’t do that.
It is seriously a waste of time. Google will help you find all of these and it is free!
And honestly, there is no shame in looking up a word you can’t remember or you aren’t quite sure is correct. Better to double check than use the wrong word. No one is going to know. Unless of course you are being pimped. Then you are on your own there bud…
Here is a PDF of what is approved for the NBOME: It starts on page 17.
A&Ox3: Alert and Oriented (x3) or to person, place, and time. You may also see A&Ox4 which is the same as above but add event.
VSS: Vital signs stable.
NAD: No acute distress.
LMP: Last menstrual cycle. You may also see LKMP: which is last known menstrual cycle. For those of you with out vaginas the cycle starts on the first day you bleed. A typical “regular” cycle is 28 days, but there is a lot of variation with this.
NC/AT: normocephalic, atraumatic.
PERRL: pupils equal, round, and reactive to light (sometimes will have an A at the end which stands for accommodation)
EOMI: extra ocular movements intact.
EAC: external auditory canal.
LAD: lymphadenopathy. (I personally hate using this one).
RRR: Regular rate and rhythm
NSR: Normal sinus rhythm
CTAB: Clear to auscultation bilaterally
ROM: Range of motion
CN II-XII: Cranial nerves 2-12
abd: abdomen
CVA (has 2 meanings): costovertebral angle (or flanks) AND cerebrovascular accident (stroke)
HTN: Hypertension
DM: diabetes mellitus
NIDDM: Non-insulin dependent diabetes mellitus
IDDM: insulin dependent diabetes mellitus
CHF: Congestive heart failure
COPD: Chronic obstructive pulmonary disease
CABG: coronary artery bypass graft. (if you hear this it will sound like “cabbage”. Do not write that. They are never talking about the vegetable cabbage.)
JVD: Jugular Venous Distension
R/O: rule out
WNL: within normal limits
LFT’s: Liver function tests
MVA: Motor vehicle accident.
Cspine/Tspine/Lspine: Use one on their own, not listed like this. Stands for cervical spine, thoracic spine, lumbar spine.
PE (has 2 meanings): Physical exam OR pulmonary edema. You need to be able to distinguish in what context you are using.
DVT: Deep vein thrombosis
URI: upper respiratory infection
I&D: incision and drainage.
There are so many. But hopefully that is a start. A lot of these should sound somewhat familiar if you’ve ever spent time in a medical setting.
This website has a few good medical words with definitions if you want to check it out: Vitality Medical.
Des Moines University has some helpful prefix and suffix information as well.
Hopefully this was somewhat helpful to a few of you! It’s hard to remember all of the terms I learned as a scribe because it was so long ago. If I can keep track of what I see again I will try to make another list, but no promises.
Cheers!
