Table I.

An example of documentation of a physical examination that can be done using limited digital equipment

Examination:
Vital signs: Weight- Height- Resp Rate- Pulse-
General: No apparent distress. Awake, alert, well-appearing.
HEENT: Normocephalic and atraumatic. Mucous membranes are moist. No periorbital edema. Facial muscles move symmetrically.
Neck: Neck is symmetrical with trachea midline.
Eyes: Conjunctiva and eyelids normal bilaterally. Pupils equal and round bilaterally.
Sinuses: Patient/guardian was able to touch the face with no tenderness. No frontal or maxillary tenderness.
Respiratory: Breathing unlabored, no tachypnea, no nasal flaring, no coughing, use of accessory muscles, chest retractions, unable to speak in complete sentences or prolonged expiratory phase.
Cardiovascular: No edema, no pallor, no cyanosis.
Abdomen: Nondistended.
Skin: No concerning rash or lesions observed on exposed skin.
Extremities: Normal range of motion observed. No peripheral edema.
Neuro: Mood and behavior appropriate for age.
Musculoskeletal: Symmetric and appropriate movements of extremities.

HEENT, Head, ears, eyes, nose, and throat.