Physical exam templates exist because of a rule that no longer applies.

Under the 1997 documentation guidelines, the extent of your examination was scored by counting bullet elements, with numeric requirements attached to them [1]. Templates were how you hit the count.

The count is gone. The templates are still circulating, and a template that pre-fills a full normal exam now records physical acts you may not have performed, in exchange for nothing.

Here is the blank template, the normal findings wording, two worked examples, and a straight account of which lines you should leave empty.

Key Takeaway: A physical exam template is a structured block for recording objective findings by body system, distinct from the review of systems, which records what the patient reports. Under the 1997 documentation guidelines the extent of the exam was scored by counting bullet elements, and templates existed to help clinicians reach those counts [1]. That scoring is retired. Since 1 January 2021 for office and outpatient visits, and 1 January 2023 for hospital, emergency, consultation and nursing facility visits, history and examination are no longer used to select the evaluation and management level, which is now based on medical decision making or total time [2][3]. The exam still has to be medically appropriate, and it still carries clinical, malpractice and quality weight [3], so a pre-filled normal exam records work that may not have happened with no billing benefit in return. Sully.ai's AI Scribe captures the exam findings you describe during the visit and writes them into the note.

What Goes in a Physical Exam Template

A physical exam template is the objective half of the note, organized by body system.

It holds what you found. Not what the patient told you, and not what you concluded.

The Systems a General Exam Covers

A general multi-system template usually runs eleven systems, from constitutional and vital signs through to lymphatic.

Templates vary in shape for a historical reason. The 1995 guidelines organized the examination by body areas and organ systems, while the 1997 guidelines organized it by bullet elements inside them [1]. Two competing structures, both retired for scoring purposes, both still visible in the templates people inherited.

Physical Exam Versus Review of Systems

The short version: the exam is performed, the review of systems is asked.

"Denies shortness of breath" is a review of systems entry, because the patient said it. "Lungs clear to auscultation bilaterally" is an exam finding, because you listened. Same organ system, different halves of the note, and exam findings belong in the objective section.

That distinction has its own consequences for documentation, covered in the review of systems template rather than repeated here.

The Physical Exam Template

Copy what you need. The point of the labels is to make it obvious which systems you are asserting on.

The Blank Template to Copy

PHYSICAL EXAMINATION

• Constitutional and vitals:

• HEENT:

• Neck:

• Cardiovascular:

• Respiratory:

• Abdomen:

• Musculoskeletal:

• Skin:

• Neurologic:

• Psychiatric:

• Lymphatic:

Delete the systems you did not examine rather than leaving them blank or filling them with a default.

The Normal Findings Template

This is the conventional wording for a normal finding in each system, of the kind clinical references collect [4]. Use a line when you examined that system and found it normal.

• Constitutional: Alert, well appearing, in no acute distress. Vital signs reviewed and stable.

• HEENT: Normocephalic, atraumatic. Conjunctivae clear, sclerae anicteric. Oropharynx clear and moist, no exudate.

• Neck:Supple, full range of motion. No lymphadenopathy, no thyromegaly, no jugular venous distension.

• Cardiovascular:Regular rate and rhythm. No murmurs, rubs or gallops. Peripheral pulses intact, no peripheral oedema.

• Respiratory: Normal effort. Lungs clear to auscultation bilaterally, no wheezes, rales or rhonchi.

• Abdomen:Soft, non-tender, non-distended. Bowel sounds present in all four quadrants. No hepatosplenomegaly, no rebound or guarding.

• Musculoskeletal: Normal bulk and tone. No joint swelling, erythema or deformity. Full range of motion throughout.

• Skin: Warm and dry. No rash, no lesions, no ecchymoses.

• Neurologic: Alert and oriented to person, place and time. Cranial nerves II to XII grossly intact. Strength 5 out of 5 in all extremities. Gait normal.

• Psychiatric: Normal mood and affect. Behaviour appropriate. Judgement and insight intact.

• Lymphatic: No cervical, axillary or inguinal lymphadenopathy.

Read the neurologic line again. It asserts that you tested twelve cranial nerves, graded strength in four limbs, and watched the patient walk. That is a lot to claim on a visit for a sore throat.

Wording That Describes What You Did

The difference between a defensible exam note and boilerplate is usually specificity, and sometimes it is just honesty about scope.

Vague: "Neuro intact." Specific: "Cranial nerves II to XII grossly intact, strength 5 out of 5 in all four limbs, gait normal."

Vague: "Chest clear." Specific: "Lungs clear to auscultation bilaterally, normal effort, no accessory muscle use."

Asserted but not performed: a full eleven-system normal block on a focused visit.Honest: four systems documented, the rest omitted, because four were examined.

The third pair is the one that matters. Omission is not a gap in your note. It is an accurate record of a focused examination.

Where Sully.ai Fits in Exam Documentation

Most clinicians describe findings out loud while examining. That is the moment the note could be written, and usually is not.

Sully.ai's AI Scribe captures what you say during the encounter and writes it into the objective section, so the exam in the note is the exam that happened rather than a block that was pasted afterwards. Clinicians can save how they want notes structured, so the systems come back in the same order every time. It runs on a single integration across Epic, Cerner, Meditech and Athenahealth.

The honest boundary: Sully records what you describe. It does not know which systems you examined, it does not verify a finding, and it will not stop anyone pasting a normal template. What it removes is the reason people paste one, which is that writing the exam out afterwards is slow.

Sully operates across 5,000+ providers, has delivered 50M+ hours of AI work, and prices each AI role 80 to 90 percent below the human equivalent [5].

Physical Exam Examples by Visit Type

Two examples, written out. Note that neither is a complete normal block.

A Focused Exam for an Acute Complaint

Visit: 34 year old with two days of sore throat and fever.

PHYSICAL EXAMINATION

• Constitutional: Alert, uncomfortable but not toxic appearing. Temperature 38.2, other vitals stable.

• HEENT: Oropharynx erythematous with bilateral tonsillar exudate. No trismus, uvula midline. Tympanic membranes clear bilaterally.

• Neck: Tender anterior cervical lymphadenopathy bilaterally. Supple, no meningism.

• Respiratory: Normal effort, lungs clear to auscultation bilaterally.

Four systems. Each one relates to the differential being worked through, and the other seven are absent because they were not examined.

A Complete Exam for an Annual Visit

Visit: 52 year old, annual preventive visit.

PHYSICAL EXAMINATION

• Constitutional: Well appearing, no acute distress. BMI 28.4, vitals reviewed.

• HEENT: Normocephalic, atraumatic. Conjunctivae clear. Oropharynx clear.

• Neck: Supple, no lymphadenopathy, no thyromegaly.

• Cardiovascular: Regular rate and rhythm, no murmurs. Trace bilateral ankle oedema.

• Respiratory: Normal effort, lungs clear to auscultation bilaterally.

• Abdomen: Soft, non-tender, non-distended. No organomegaly.

• Musculoskeletal: Full range of motion, no joint swelling or deformity.

• Skin: Warm and dry. Two benign appearing seborrhoeic keratoses on the upper back, unchanged by report.

• Neurologic: Alert and oriented. Cranial nerves grossly intact. Strength 5 out of 5 throughout. Gait normal.

• Psychiatric: Normal mood and affect.

Ten systems and two abnormal findings. A completely normal example would be tidier and would teach the wrong habit, because a real exam usually finds something.

What the Exam No Longer Does

The physical exam stopped determining your billing level, and most templates still in circulation were designed for the era when it did.

Bullet Counting Is Retired

The 1997 guidelines set out the examination in tables where, in their own words, "the content, or individual elements, of the examination pertaining to that body area or organ system are identified by bullets" [1]. Each element had to satisfy any numeric requirement attached to it, such as measuring any three of seven listed vital signs [1].

That is what a physical exam template was originally for. Reaching a number.

Since 1 January 2021 for office and outpatient visits, and 1 January 2023 for hospital, emergency, consultation and nursing facility visits, history and examination are no longer used to select the evaluation and management level [2][3]. AMA revised the descriptors to call for a "medically appropriate history and/or examination" instead [6]. The fuller version of that regulatory story sits with the review of systems, which the same revisions retired.

Why a Pre-Filled Normal Exam Is the Risk

Here is the part specific to the exam, and it is worth separating from the equivalent problem in the review of systems.

A review of systems entry is a claim about a question you asked. A physical exam finding is a claim about a physical act you performed.

"Denies chest pain" says the patient told you something. "No murmur on auscultation" says you placed a stethoscope on a chest and listened. When a template fills that line by default, the note asserts work rather than a conversation.

Under the old rules there was at least a reason people did it, because more documented elements meant a higher level. That reason is gone. The exposure is not.

What the Exam Still Carries

None of this means the examination stopped mattering. It means it stopped being scored.

AAFP is specific that history and physical exam elements remain necessary for clinical practice, for professional liability reasons, and for quality measurement, even though they are no longer components of level selection [3].

And there is an indirect route back to the code. The level now rests on medical decision making, which is judged partly on the problems you addressed and the risk you managed. Those are conclusions the exam supports. A thin exam does not lower your level directly, but it can leave the assessment above it looking unsupported.

Book a demo and bring a focused visit. The question worth asking is how many systems your current template asserts on versus how many you examined.

FAQ

Q: What is included in a physical exam template? A block for objective findings by body system: constitutional and vital signs, HEENT, neck, cardiovascular, respiratory, abdomen, musculoskeletal, skin, neurologic, psychiatric and lymphatic. Which systems you complete depends on what you examined [1].

Q: What is the difference between a physical exam and a review of systems? The exam is what you perform and observe. The review of systems is what you ask and the patient answers. Exam findings are objective and belong in the objective section of the note, while the review of systems belongs in the subjective section.

Q: Does the physical exam affect the E/M level? Not directly, and not since the guidelines changed. History and examination are no longer used to select the level, which is based on medical decision making or total time [2][3]. The code descriptors still call for a medically appropriate examination [6].

Q: Can I use a normal physical exam template for every patient? Only for the systems you actually examined. A normal finding asserts that you performed the examination and it was normal, so pre-filling systems you did not examine records work that did not happen, and since bullet counting was retired there is no billing benefit in return [2][3][1].

Q: Do you have a free physical exam template? Yes. The blank template and the normal findings wording are both on this page as copy-paste blocks, with two worked examples. Sully.ai's AI Scribe can also capture the findings you describe during the exam and write them into the objective section of the note.

Sources

[1] Centers for Medicare & Medicaid Services — 1997 Documentation Guidelines for Evaluation and Management Services [2] Centers for Medicare & Medicaid Services — Evaluation and Management Services, MLN006764 [3] American Academy of Family Physicians — Evaluation and Management Coding [4] WikEM — Physical Exam Documentation [5] Sully.ai — The AI Workforce for Healthcare [6] American Medical Association — CPT Evaluation and Management