The health record generated during a physical examination documents a person’s health status at a specific point in time. This paperwork is a meticulously organized clinical narrative and data repository, far more than a simple receipt of the visit. The documentation provides a standardized, legally compliant record that communicates a patient’s history, current findings, and future care directives to other healthcare professionals. This medical dossier forms the official basis for all subsequent health management decisions and certifications.
Patient History and Administrative Forms
The process begins with the collection of administrative and self-reported medical information. Patients typically complete forms detailing their past medical history (PMH), which includes prior diagnoses, surgeries, and hospitalizations. This section also requires a comprehensive list of all current prescription and over-the-counter medications, including dosages, to identify potential drug interactions or contraindications.
Family history (FH) documents the health status of immediate blood relatives. This information helps the clinician assess hereditary risks for conditions like heart disease, diabetes, or certain cancers. The social history (SH) covers lifestyle factors such as tobacco and alcohol use, occupation, and exercise habits, offering insight into environmental or behavioral risks.
Consent forms and privacy declarations are executed during this initial phase. These administrative documents confirm the patient’s understanding and acceptance of the practice’s policies and authorize the sharing of their protected health information (PHI) under specific conditions. This early documentation layer is based on the patient’s perspective and demographic data, setting the foundation for the objective clinical evaluation.
The Clinical Examination Record
The core of the documentation is the clinical examination record, which captures the provider’s direct, objective observations and measurements. This section starts with quantitative data, the patient’s vital signs. These measurements include blood pressure, heart rate, respiratory rate, and body temperature, alongside anthropometric data like height, weight, and the calculated Body Mass Index (BMI).
Following the initial measurements, the clinician documents systematic findings by body system, often using standardized terminology and abbreviations. The general appearance is noted, covering the patient’s level of distress, consciousness, and nutritional status. The assessment then proceeds through the major systems, such as the head, eyes, ears, nose, and throat (HEENT), cardiovascular, pulmonary, and abdominal systems.
The provider records specific findings for each system, noting whether an observation is within normal limits (WNL) or documenting any positive or pertinent negative findings. A cardiovascular assessment, for example, documents the rate and rhythm of the heart sounds (S1 and S2) and notes the absence or presence of murmurs or extra sounds. These detailed notes create a clear picture of the patient’s physical presentation.
Interpreting Laboratory and Diagnostic Reports
A physical examination often includes laboratory testing, the results of which are integrated into the medical record. These reports present quantitative data, such as the Complete Blood Count (CBC) and Metabolic Panels, which offer a biochemical snapshot of the patient’s internal function. The Basic Metabolic Panel (BMP), for example, measures eight substances including glucose, calcium, and several electrolytes like sodium and potassium.
These tests provide information on kidney function through measurements of Blood Urea Nitrogen (BUN) and creatinine, and they also assess fluid and electrolyte balance. The Comprehensive Metabolic Panel (CMP) expands on the BMP by adding liver function tests, such as enzymes like Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST), to evaluate liver health. Each lab result is presented with a specific numerical value and a laboratory-defined reference range.
The diagnostic reports require a physician’s interpretation note to explain the clinical significance of any abnormal findings in the context of the patient’s overall health. This interpretation, along with the raw data, becomes part of the treatment history and is used to monitor existing conditions or screen for new health issues.
The Final Medical Summary and Certification
The final medical summary is typically formatted around the Assessment and Plan (A/P). The Assessment section synthesizes all collected data—the patient’s history, clinical examination findings, and laboratory results—to formulate a concise diagnosis or impression of the patient’s health status. This section may include a discussion of any differential diagnoses considered by the clinician.
The corresponding Plan outlines the recommended next steps for patient care, which may include follow-up testing, medication adjustments, lifestyle modifications, or specialist referrals. The plan is often broken down by problem or system, ensuring that all health concerns addressed during the visit have a clear management strategy.
For physicals required by external entities like employers or schools, a separate certification form is often completed based on the comprehensive record. This final document, such as a “Fit for Duty” or “Cleared for Sports” certification, requires the physician’s official signature and date, certifying the validity of the documented examination. The entire medical record is then securely stored, adhering to federal standards.