So I am really frustrated by the Physical Exam heading. I can’t figure out when to list the different areas examined followed by a colon and when to transcribe everything into a paragraph. Does anyone have any idea on an easy way to know when to list and when not to list?
You need to look at the sentences within the physical exam. Similar to deciding if you have a major heading or a sentence at the start of each paragraph, you need to decide if each sentence is a regular sentence or has a subheading at the start.
The key to this is to look to see if a verb was dictated that applies to your ‘potential subheading.’ Here are a few examples:
Extremities show 2+ edema. (Is this a subheading or sentence? The verb ‘show’ applies to your potential subheading “extremities,” so this should be formatted as a regular sentence.)
Extremities edematous with excoriations on the left lateral calf. (Is this a subheading or sentence? There is no verb which applies to ‘extremities,’ so this should become a subheading.)
Correction = Extremities: Edematous with excoriations on the left lateral calf.
As soon as you have a subheading within an exam, you need to change the formatting of the entire exam to stacked/list format. This means that each new section of the exam should have a line of its own.
So I guess my next question is after deciding whether it is a subheading or not, should you separate each individual area examined and display them in a list format, use a paragraph format for everything under the Physical Exam heading, or use sentences for the appropriate areas and then list the other parts on a new line?