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Primary Care Physician
15-20 minutes

Comprehensive Physical Examination

The Comprehensive Physical Examination template by s10.ai is an indispensable resource for General Practitioners performing detailed health evaluations. This template streamlines the documentation process for patient assessments, encompassing medical history, immunization records, cancer screenings, and cardiovascular risk evaluations. It also includes meticulous physical examination findings and management strategies. Utilizing this template with s10.ai ensures that every facet of a patient's health is thoroughly reviewed and documented, promoting seamless continuity of care and proactive health management. Ideal for annual check-ups and the management of chronic conditions such as diabetes and hypertension, this template empowers clinicians to enhance patient outcomes effectively.

2,408 uses
4.4/5.0
J
James Anderson
Template Structure

Organized sections for comprehensive clinical documentation

Billing codes: 03.04A CMX30 (comprehensive physical examination) +/- 13.99BA (pelvic examination with pap smear)
ICD-9 codes: [suggest potential ICD-9 codes relevant to the visit]
Title: Complete: [provide a title for the visit that encapsulates any specific management, such as tests ordered or prescriptions]
Summary: Comprehensive Health Evaluation - [briefly summarize any specific concern or management plan beyond just a complete assessment, e.g., tests ordered or medications prescribed]
Review of medical problems & medication renewals:
[list any medical issues discussed, along with any details, and any medications taken regarding these conditions and any management of those conditions]
(use "- " to indicate list items, and, if necessary, use "-- " to indicate sub-items in lists)
Patient concerns: [list any additional concerns the patient brought up]
Immunizations:
- [list any information regarding immunizations]
Cancer Screening:
- Colorectal: [information regarding colorectal cancer screening or risk factors]
- Lung: [information regarding lung cancer screening or risk factors]
- Cervical: [information regarding cervical cancer screening] (omit if male)
- Breast: [information regarding breast cancer screening or risk factors] (omit if male)
- Prostate: [information regarding prostate cancer screening or risk factors] (omit if female)
Cardiovascular Risk Assessment and Reduction:
- [list any information regarding Cardiovascular Risk Assessment and Reduction, e.g., BMI, family history of heart disease, smoking history, alcohol and drug use, exercise, diet, lipids, hypertension, and cardiac investigations]
Other screening:
- [list any information regarding other routine screening, e.g., screening for diabetes, osteoporosis, abdominal aortic aneurysm, STIs, etc.]
Exam:
- General inspection: [unless otherwise noted, state "alert and appropriate throughout encounter, in no apparent distress, overall well appearing"]
- HEENT:
- Cardiac:
-- Blood pressure:
- Respiratory:
- Abdomen:
- Derm: [unless otherwise noted, state "no concerning lesions noted"]
- Neuro: [unless otherwise noted, state "grossly normal"]
[list any other exam findings]
Assessment and management:
- [list all management plans. even if mentioned above, reiterate the management plan here so that all management plans can be reviewed together]
- [unless otherwise mentioned state "Follow up in 12 months for repeat complete exam"]
Sample Clinical Note

Example of completed documentation using this template

Billing codes: 03.04A CMX30 (comprehensive physical examination) +/- 13.99BA (pelvic exam with pap smear)  
ICD-9 codes: 250.00 (Diabetes Mellitus), 401.1 (Hypertension)
Title: Comprehensive: Yearly Physical Examination with Diabetes and Hypertension Management
Summary: Thorough Health Assessment - HbA1c test ordered and hypertension medication adjusted
Review of medical problems & medication renewals: 
- Diabetes Mellitus
  -- Metformin 500mg twice daily
  -- HbA1c test ordered
- Hypertension
  -- Lisinopril 10mg daily
  -- Advised to monitor blood pressure
Patient concerns: 
- Occasional headaches
- Trouble sleeping
Immunizations: 
- Influenza vaccine given
- Tetanus booster due in 2025
Cancer Screening: 
- Colorectal: No family history, colonoscopy planned for next year
- Lung: No risk factors, non-smoker
- Cervical: Pap smear completed, awaiting results
- Breast: Mammogram planned, no family history
Cardiovascular Risk Assessment and Reduction:
- BMI: 28
- Family history of heart disease
- Non-smoker
- Alcohol: Social consumption
- Exercise: Regular walking
- Diet: Advised to decrease salt intake
- Lipids: Cholesterol levels normal
- Hypertension: Managed with medication
Other screening:
- Diabetes: HbA1c test ordered
- Osteoporosis: No risk factors
- STIs: Not at risk
Exam: 
- General inspection: Alert and appropriate throughout encounter, no apparent distress, overall well-appearing
- HEENT: Normal
- Cardiac: Regular rate and rhythm
  -- Blood pressure: 130/85 mmHg
- Respiratory: Clear to auscultation
- Abdomen: Soft, non-tender
- Derm: No concerning lesions noted
- Neuro: Grossly normal
Assessment and management:
- Continue Metformin and Lisinopril
- HbA1c test to monitor diabetes
- Blood pressure monitoring
- Follow up in 12 months for repeat comprehensive exam
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template for a Complete Physical Exam is designed to streamline the documentation process for healthcare professionals, ensuring thorough patient assessments and efficient management planning. It includes billing codes 03.04A CMX30 for a complete physical exam and 13.99BA for a pelvic exam with pap smear, along with relevant ICD-9 codes for accurate medical coding. The template facilitates a detailed review of medical problems and medication renewals, addressing patient concerns and immunization updates. It incorporates essential cancer screenings, including colorectal, lung, cervical, breast, and prostate, tailored to patient gender. The cardiovascular risk assessment section evaluates BMI, family history, lifestyle factors, and cardiac investigations, while other routine screenings cover diabetes, osteoporosis, and more. The exam section provides a structured approach to general inspection, HEENT, cardiac, respiratory, abdominal, dermatological, and neurological evaluations. The assessment and management section consolidates all management plans, ensuring a comprehensive follow-up strategy, typically recommending a 12-month interval for the next complete exam. This template is an invaluable tool for clinicians seeking to enhance patient care and optimize clinical workflows.
Frequently Asked Questions

Common questions about this template and its usage

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