Sports Physical Documentation Template

Overview

Pre-participation physicals (PPEs) are time-pressured, high-volume events where documentation quality often suffers. But the sports physical note carries real liability exposure - particularly around cardiac screening and musculoskeletal clearance decisions. A thorough, structured note doesn't just protect you: it's the right thing to do for the 1 in 300 athletes with a previously undetected cardiac condition. This template covers every AHA 12-element screening requirement and leaves you ready for any school form.

HPI Example

Patient is a 16-year-old male presenting for pre-participation physical evaluation for high school football. No current symptoms. Denies exertional chest pain, shortness of breath, or syncope at any time. No history of prior concussion, musculoskeletal injury, or prior cardiac evaluation or restriction from sports. Reports no use of dietary supplements, protein powders, or performance-enhancing substances. Family history negative for sudden cardiac death before age 50, hypertrophic cardiomyopathy, Marfan syndrome, Long QT syndrome, or early coronary artery disease. No personal history of asthma or exercise-induced bronchospasm. Immunizations up to date per patient and parent report.

ROS Example

Constitutional: No fatigue, unexplained weight loss, or systemic illness. Cardiovascular: Denies exertional chest pain, exertional dyspnea, palpitations, syncope, or near-syncope. Denies prior cardiac diagnosis or family history of sudden cardiac death. Respiratory: Denies exertional wheezing, cough, or known asthma. Musculoskeletal: Denies active joint pain or prior fractures requiring surgery. Reports mild anterior right knee pain when climbing stairs - onset 4 weeks ago. Denies locking, giving way, or swelling. Neurologic: Denies recurrent headaches, dizziness, or prior concussion.

Physical Exam Example

Vitals: T 98.6°F, HR 68, BP 116/72, RR 14, Wt 165 lbs, Ht 5'10", BMI 23.7 General: Well-appearing adolescent male in no distress HEENT: PERRL, EOM intact. TMs clear bilaterally. Hearing grossly intact. Oropharynx clear. Cardiovascular: Regular rate and rhythm. Normal S1/S2. No murmurs appreciated at rest, with Valsalva maneuver, or upon standing. No clicks. No JVD. Radial and femoral pulses 2+ and equal bilaterally. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, flat, non-tender. No hepatosplenomegaly. Musculoskeletal: Full ROM bilateral upper and lower extremities. Right knee: mild anterior tenderness at inferior patellar pole. Negative Lachman, negative McMurray, negative valgus/varus stress. No effusion. Single-leg squat: mild anterior knee discomfort reproduced. Duck walk: completed without difficulty. Neurologic: CN II–XII grossly intact. Strength 5/5 bilateral. Coordination and gait normal. Marfan Screen: No arachnodactyly, pectus excavatum, high-arched palate, or disproportionate extremity length.

MDM Example

Problems Addressed: 1. Pre-participation sports physical - AHA 12-element history and physical performed and documented 2. Right anterior knee pain - likely patellar tendinopathy; no structural pathology on exam Data: No imaging or lab data reviewed. Physical examination findings as above. Risk: Minimal - preventive exam; management recommendation only Overall MDM Level: Straightforward (supports 99382 preventive or appropriate E/M code per payer) Clinical decision-making: No cardiac pathology identified on history or physical. No murmur at rest or with provocation. No syncope, exertional symptoms, or family history of sudden cardiac death. Right knee exam reveals anterior patellar pole tenderness consistent with patellar tendinopathy - no evidence of ligamentous instability or intra-articular pathology on clinical exam. Athlete cleared for full participation. Knee pain managed conservatively with quad strengthening; instructed to report if worsening or if swelling develops.

Smart Phrase

.SPORTPHYS Pre-Participation Physical - [Sport], [Grade/Level] HPI: [Age] [sex] presenting for PPE for [sport]. Denies exertional chest pain, SOB, syncope, or prior cardiac evaluation or restriction. No hx of concussion. [No prior injuries / Hx of: ___]. FH: [Negative for SCD before 50, HCM, Marfan, Long QT / Positive for: ___]. AHA Cardiac Screen: No exertional symptoms, syncope, or palpitations. No prior cardiac restriction. Cardiac Exam: [RRR, no murmurs at rest, with Valsalva, or standing. Pulses equal bilaterally]. MSK Screen: [Full ROM bilateral UE/LE. Duck walk and single-leg squat without difficulty / Limited by: ___]. Marfan Screen: [No features of Marfan syndrome identified]. Decision: [CLEARED for full participation in ___ / Cleared with restrictions: ___ / NOT cleared - referred to: ___]. Counseling: Hydration and heat illness prevention. Concussion recognition and return-to-play protocol reviewed. Substance use counseled.

Documentation Tips

• The AHA 12-element PPE must be documented - not just that you performed it. List each element or use a structured checklist that attaches to the chart.
• Always document the Valsalva and standing cardiac exam. These specifically screen for HOCM and are defensible if a young athlete later collapses.
• Document your Marfan screening explicitly. Marfan syndrome is a leading cause of sudden cardiac death in young athletes and is often missed.
• For murmurs on PPE: document innocent vs. pathologic characteristics. An innocent murmur decreases with Valsalva; HOCM murmur increases.
• Write the clearance statement clearly and specifically: 'Cleared for full participation in football' - not just 'no contraindications identified.'

Related Documentation Guides

• URI Documentation Template
• Chest Pain Documentation Example