The Sports Physical Template by s10.ai is an all-encompassing documentation resource tailored for sports medicine professionals performing pre-participation physical assessments. This template facilitates a detailed evaluation of an athlete's medical and family history, physical examination, and musculoskeletal assessment, crucial for detecting potential health risks linked to sports activities. Integrated with s10.ai's AI medical scribe, it enhances the documentation workflow, ensuring comprehensive and efficient capture of all relevant information. This template is perfect for clinicians aiming to issue clearances for athletes across diverse sports disciplines.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
Subjective:s10.ai is a 16-year-old male presenting today for a sports physical exam.Sports: Soccer, BasketballMedical History:- Prior orthopedic injury: Denies- History of concussion: Denies- History of exertional chest pain/discomfort or palpitations: Denies- History of unexplained syncope/near syncope: Denies- Excessive exertional and unexplained dyspnea/fatigue: Denies- Prior history of a heart murmur: Denies- History of high blood pressure: DeniesPertinent Family History:- Family history of premature death (sudden and unexpected, or otherwise) before age 50yrs due to heart disease: Denies- Family history of disability from heart disease in a close relative <50yrs of age: Denies- Family history of specific cardiac conditions (hypertrophic or dilated cardiomyopathy, long QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias): DeniesPhysical Exam:Vision: R20/20 L20/20 OU20/20General: A&O x3, in no acute distressHEENT: PERRLA, EOMI, normal oropharynx, normal tympanic membranesNeck: No lymphadenopathy, no neck vein distension, no thyromegalyCardiovascular: RRR no MRG with squatting or standingRespiratory: equal breath sounds bilaterally; no rales, rhonchi, or wheezesAbdomen: Soft, non-tender, non-distended, normal BS in all quadrants; no palpable hepatomegaly or splenomegalyGU: DeferredSkin: no rash, no abnormalitiesMusculoskeletal:- General: Symmetric upper extremities, lower extremities, trunk- Neck: full ROM in all directions; able to touch chin to chest and ears to shoulders- Back: symmetric back with no signs of spinal curvature when standing straight or bent over to touch toes- Shoulder/Arm: 5/5 strength in deltoids; ROM- normal flexion, extension, internal and external rotation- Elbow/forearm: 5/5 strength in biceps, and triceps; ROM- normal extension, flexion, supination, and pronation- Wrist/hand: 5/5 strength in wrist flexion, wrist extension, and finger interossei- Hip/thigh/knee: able to squat on heels and duck walk for at least four steps without pain, heel to buttock distance is equal on both sides and knee flexion is equal during the walk- Leg/ankle/foot: able to walk on heels and toes; symmetric calf muscles- Signs of Marfans syndrome: negative for pectus excavatum, thumb sign, and wrist signSpecific Pertinent Physical Exam Findings:- Blood Pressure: Normal BP- Cardiac auscultation: No cardiac murmur identified with dynamic cardiac auscultation- Pulse examination: Normal simultaneous palpation of radial and femoral pulses- Marfan's syndrome screening: No signs of Marfan's syndrome (as above)ASSESSMENT/PLAN:No concerns at this time. Pt cleared for all activity.Additional Notes:See scanned athletic participation form for further details regarding sports-related medical history and ROS
Key advantages of using this template in clinical practice
Common questions about this template and its usage