{List all abnormal findings first, organized by system. If no abnormal findings are mentioned for a system, skip it. Use concise formal clinical language.}

GENERAL APPEARANCE: [List abnormal findings if present]  
VITAL SIGNS: [List abnormal findings if present]  
HEENT: [List abnormal findings if present]  
RESPIRATORY: [List abnormal findings if present]  
CARDIOVASCULAR: [List abnormal findings if present]  
GASTROINTESTINAL: [List abnormal findings if present]  
GENITOURINARY: [List abnormal findings if present, prefixed Male or Female]  
LYMPHATIC: [List abnormal findings if present]  
BACK, MUSCULOSKELETAL: [List abnormal findings if present]  
EXTREMITIES: [List abnormal findings if present]  
SKIN: [List abnormal findings if present]  
NEUROLOGICAL: [List abnormal findings if present]  
PSYCHIATRIC: [List abnormal findings if present]  
OTHER OBSERVATIONS: [List abnormal findings if present]  

{Insert a single blank line between abnormal and normal sections}

GENERAL APPEARANCE: "Patient is in no acute distress, well-developed, well nourished, and not ill-appearing." {If GENERAL APPEARANCE mentioned above, then delete this line.}

VITAL SIGNS: "Vitals and nursing note reviewed." {If VITAL SIGNS mentioned above, then delete this line.}

HEENT:  
"Head: Normocephalic and atraumatic." {If HEAD mentioned above, then delete this line.}  
"Eyes: No discharge, EOMI, conjunctiva clear, and PERRL." {If EYES mentioned above, then delete this line.}  
"Ears: TM, canal, and external ears normal bilaterally." {If EARS mentioned above, then delete this line.}  
"Nose: No congestion or rhinorrhea." {If NOSE mentioned above, then delete this line.}  
"Mouth: Mucous membranes moist." {If MOUTH mentioned above, then delete this line.}  
"Pharynx: No erythema, exudate, or tonsillar enlargement." {If PHARYNX mentioned above, then delete this line.}

RESPIRATORY:  
"Effort: No respiratory distress." {If RESPIRATORY EFFORT mentioned above, then delete this line.}  
"Breath sounds: Clear bilaterally. No wheezing or rales." {If BREATH SOUNDS mentioned above, then delete this line.}

CARDIOVASCULAR: "Regular rate and rhythm. No murmurs, gallops, or rubs. Brisk cap refill." {If CARDIOVASCULAR mentioned above, then delete this line.}

GASTROINTESTINAL: "Soft, non-tender, non-distended. No guarding or rebound." {If GASTROINTESTINAL mentioned above, then delete this line.}

GENITOURINARY: [Insert findings (prefixed Male or Female). If no GU exam was verbally described or noted above, write “GU deferred.” Otherwise, include findings. If chaperone was mentioned, document below.]

LYMPHATIC: "No cervical, axillary, or inguinal lymphadenopathy." {If LYMPHATIC mentioned above, then delete this line.}

BACK, MUSCULOSKELETAL: "No abnormal or restricted ROM. No scoliosis or pain with movement." {Only include if BACK, MUSCULOSKELETAL mentioned above; otherwise delete this line.}

EXTREMITIES: "No deformities, cyanosis, or edema." {If EXTREMITIES mentioned above, then delete this line.}

SKIN: "Warm and dry. No rash or lesions." {If SKIN mentioned above, then delete this line.}

NEUROLOGICAL: "Alert and oriented for age. Normal tone and reflexes." {If NEUROLOGICAL mentioned above, then delete this line.}

PSYCHIATRIC: "Mood and affect appropriate. Behavior normal for age." {If PSYCHIATRIC mentioned above, then delete this line.}

OTHER OBSERVATIONS: [Insert any other relevant findings.] {If not mentioned, delete this line.}