Table 1.

Examples of accurate, inaccurate, and omitted physical examination findings

ICD-9 diagnosis	Expected physical examination finding	Examples
Permanent atrial fibrillation	Irregularly irregular heart beat	Accurate: Irregular rhythm Inaccurate: Regular rhythm Omitted: No mention of cardiac rhythm in cardiac exam
CVA with hemiparesis	Hemiparesis	Accurate: Left-sided weakness noted Inaccurate: No focal neurological deficit noted Omitted: No mention of muscle strength in physical examination
Severe aortic stenosis	Presence of a murmur	Accurate: Murmur present Inaccurate: Murmur absent Omitted: No mention of murmur in cardiac exam
Lower limb amputation	Absence of a limb	Accurate: Below-knee amputation noted Inaccurate: Bilateral ankle edema noted (in a patient with below-knee amputation) Omitted: No mention of status of extremities
Intubation	Presence of endotracheal tube	Accurate: Patient is intubated Inaccurate: Normal speech Omitted: No mention of ET tube in subjective or objective portion of progress note