Posted: September 4th, 2023

Perform the specific body system exam on the patient

Perform the specific body system exam on the patient
Do not include CC, HPI, ROS or any other component, only the exam
Document your findings as you would for a comprehensive system exam (only document the physical findings)
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Guidance on how to perform a physical examination and document your findings.

When performing a physical examination on a patient, it is important to follow a systematic approach. Begin with a general survey of the patient’s appearance and demeanor, followed by an assessment of vital signs including blood pressure, heart rate, respiratory rate, and temperature. Then proceed to a head-to-toe examination, including inspection, palpation, percussion, and auscultation as appropriate for each body system.

For example, if performing a cardiovascular system exam, you would begin by assessing the patient’s general appearance, followed by taking their blood pressure, heart rate, and respiratory rate. You would then perform an inspection of the chest, palpation of the chest and abdomen, percussion of the chest, and auscultation of the heart and lungs. Document your findings for each aspect of the exam, including any abnormalities or normal variations observed.

It is important to use appropriate medical terminology when documenting your findings to ensure clear and accurate communication with other healthcare providers. You can refer to medical textbooks or online resources for guidance on proper terminology and documentation.

Remember to respect patient privacy and obtain their consent before performing any physical examination.

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