Physical Examination Report Sample

Generally a well developed slightly obese elderly black woman sitting up in bed breathing with slight difficulty. History and physical examination h p examples the links below are to actual h ps written by unc students during their inpatient clerkship rotations. On admission temperature 98 5 blood pressure 142 89 pulse 105 respiratory rate 21 and o2 saturation 98 on room air.

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A physical exam is a way of conducting preventive treatment for everyone regardless of race age sex or level of activity.

Physical examination report sample. Health is wealth as an old adage says which is why having periodic physical exams are necessary. She complains of resolving chest pain. Physical examination report failure to return this completed form by. The examiner observes pokes and prods the patient and records the results here.

The patient is a well developed well nourished female male in no acute distress. Pe sample 1 physical exam format 2. Well developed well nourished female in some discomfort but no acute cardiopulmonary distress. Subheadings in all caps and transcribed in paragraph format.

A physical report is a type of report that is given after a physical examination has taken place and is often times used as a way to determine a person s physical capabilities and whether they are able to physically handle the task assigned to them. Pupils equal round and reactive to light and accommodation. Sclerae conjunctivae and fundi are clear bilaterally. The physical examination pe is an objective assessment of the patient s condition.

In some report types a brief focused exam may be conducted but an exam done as part of an h p typically assesses the patient from head to toe one body system at a time. She is awake alert and oriented x3. A physical exam is a way to screen an individual for diseases ailments. The patient is alert and oriented x3 and in slight distress secondary to pain.

This type of report normally requires the use. 7 sample physical report forms in word pdf. The students have granted permission to have these h ps posted on the website as examples. Temperature 98 4 pulse 72 respirations 20 and blood pressure is 118 76.

The patient is alert and oriented and in no acute distress. Head is normocephalic with normal hair distribution. To department of licensing dol may result in the suspension of the driver s driving privilege. Temperature 100 2 pulse 96 regular with occasional extra beat respiration 24 blood pressure 180 100 lying down 2.

Name last first middle date of birth area code daytime telephone number driver license number consent to release information.