Unremarkable
Formal Definition
A documentation term indicating that a physical exam finding, imaging result, or test result is within normal limits and contains no clinically significant abnormalities.
How It's Used on the Ward
"Abdomen unremarkable" — in chart-speak it means normal. Overused to the point where it can obscure what was actually examined.
Example
""Resident's note: 'lungs clear to auscultation, abdomen unremarkable, extremities unremarkable.' Attending: 'What does unremarkable mean? Did you feel the spleen? Was there tenderness?'""
Clinical Context
Unremarkable is acceptable shorthand but should never substitute for specificity when findings matter. A normal spleen exam is "spleen not palpated, no splenic dullness" — not "abdomen unremarkable." In student notes, be specific: show the examiner you actually looked.
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