What should be included in a physical examination section of a medical note?

The physical examination section of a medical note should clearly document vital signs and significant observations. This is essential because it provides a snapshot of the patient's current physiological status, which is crucial for diagnosing and managing their health. Vital signs, such as heart rate, blood pressure, respiratory rate, and temperature, offer important baseline information, while significant observations include any pertinent physical findings that may indicate issues requiring further investigation or immediate intervention.

In contrast to this, focusing exclusively on negative findings, documenting only personal history, or detailing patient's lifestyle choices would not fulfill the purpose of the physical examination section. These aspects, while important in the overall patient evaluation, do not directly align with the observations made during the physical exam itself. The aim of this section is to succinctly capture relevant physical findings that contribute to the clinical understanding of the patient at the time of the examination.