GENERAL APPEARANCE
NAD, activity normal for age, well developed/ well nourished, no cyanosis, 
pallor, or diaphoresis.
EYES
lids/conjunctiva normal.
EARS/NOSE/THROAT
Mucous membranes moist, nares normal, lips/teeth normal uvula midline without 
oral pharyngeal erythema, exudate or swelling
TMs normal bilaterally.
No lymphangitis/lymphedema.
HEAD/NECK
normocephalic atraumatic, no facial trauma, neck is supple.
RESPIRATORY
respiratory effort normal, speaks in full sentences, no tripod position, no 
accessory muscle use.
Lungs clear to auscultation without rhonchi, wheezes, rales
CARDIAC
Regular rate and rhythm, no edema.
ABDOMINAL Soft, ND/NT. No evidence of fluid wave. No pulsatile masses on exam, rebound tenderness, Murphy sign or pain over Mcburney's point.
MUSCLES/EXTREMITIES
No abnormal range of motion, no swelling.
SKIN
Warm, pink and dry. No rashes, dermatoses, petechiae or lesions.
NEUROLOGICAL
Speech is clear and appropriate. Normal level of consciousness. Gait and coordination are normal. 5/5 strength in all extremities.
PSYCH
Normal mood and affect. Judgement/competence is appropriate
[This template meets CMS level 5 standards]
Physical exam documentation
Pediatric assessment triangle
Documentation for emergency physicians
In-training exam review
Sign out tools
Reexamination sample documentation
Critical care documentation
Field trauma triage