Here are some guidelines to help you capture all the critical details during a physical exam:
1. Introduce the exam |
“Moving on to the physical exam…” or “Let’s take a look…” |
2. Tie findings to a location on the body |
Recommended: “Both ears are clear of blockagesAvoid: “All clear over here.” |
3. Use specific sensory words |
Recommended: “I am palpating your neck, and I feel a swollen lymph node.”Avoid: “There’s swelling in your neck.” |
4. Expect Abridge to reflect your words as spoken |
Saying “Heart exam is normal” will output “Heart exam is normal,” not a list of templated findings such as “Heart has regular rate and rhythm.” |