NextGen Knowledge Center

Document Abnormal Findings in the Hand

  1. Open the SOAP template.
  2. In the Physical Exam panel, click Hand in the left pane.
    The right and left options appear in the sub-menu.
  3. Click right to open the Hand Right - PE template or click left to open the Hand Left - PE template.
  4. In the Location 1, Location 2, Location 3, Location 4, and Location 5 panels, click the Region field and select an option from the corresponding list.
  5. In the Inspection section, click the following fields and select an option from the corresponding lists:
    • Skin/scar
    • Nails
    • Wound/laceration/burn
    • Swelling
    • Deformity/contracture
    • Mass/Foreign body
    • Tenderness
    • Laxity/stability

    If the PE findings are normal, select the All normal checkbox.

  6. In the Range of Motion section, select Normal or click the field to select an option from the list. Enter details in the following fields from the corresponding lists and windows:
    • Movement Type
    • Active ROM
    • Passive ROM
    • Distance from palmar crease
  7. In the Strength section, select Normal.
  8. Click the field to select an option from the list.
  9. In the Range of Motion panel, click the Factors and Description fields of the following fields and select the required options from the corresponding lists:
    • Shoulder
    • Elbow
    • Wrist

    If the PE findings are normal, select the Normal checkbox for the above fields.

  10. In the Strength panel, click the Strength Upper Extremity link.
    The Upper Extremity Strength - PE template appears.
  11. Enter the PE findings in the Strength - Description and Strength - Measurement sections.
  12. Click Save & Close to display the data in the respective fields.
  13. In the Neurovascular panel, click the Neurovascular Upper Extremity link.
    The Neurovascular UE - PE template opens.
  14. Enter data in the Description, Measurement, Reflexes, Sensation, Static Two Point Discrimination Pluses, Vascular Tests, and Neuro Tests sections.
  15. Click Save & Close.
    The Infections, Tendon Conditions, Tumors, Ligamentous Conditions, and Skin/Nerve Conditions links open templates to add more information about the injury. The blue link turns pink with a diamond icon to indicate that information is entered in the templates.
  16. In the Comments field, enter your comments.
  17. Click OK.
Document Abnormal Findings in the Hand