e.g. do you use paperforms, EHR masks? Do you type directly into a physician letter? In Germany we use mostly a paper form in the first place and afterwards we document the results into a report. You have to document the physical examination manually twice, which costs a lot of time. A detailed explanation of the daily workflow for the documentation of the physical examination in the USA would be very helpful.

2 Answers 2


I agree with the other answer and wanted to add a few things.

At most larger healthcare systems in the USA, EHRs are used. Paper is still sometimes used in smaller practices, but rarely.

In the USA physician documentation is called notes, not letters. Letters generally are directed to a particular individual, for example to a specialist or work note, etc.

I'm not sure what a mask is? In EHR there are usually templates that are brought into a note. They have pretyped sections with blanks you can jump to and type in details. Or there are click boxes that auto-write the text of the findings you select into the note. They bring in things from vitals to lab values to medications to diagnoses/PMH/etc.

Daily workflow wise, ideally you're able to finish the note with the patient in the room or immediately after leaving. But in our over-stretched system, often physicians end up with a bunch of charting to finish at the end of the day. That includes physical findings that are remembered and input later.

The burden of documentation sometimes (or often) takes more time than the time spent actually speaking with or examining a patient.


It varies. If you are in a system with an EHR, then there is often a template for the physical exam. Otherwise, it can be typed manually. Some systems without EHRs still use paper charting. I am unaware of anyone having to formally document the physical exam twice. Some will chart on a computer while in the room with a patient; others will simply remember the findings and document them after they have left the room.


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