Document Abnormal Findings in the Knee

Open the SOAP template.
In the Physical Exam panel, click Knee in the left pane.
The Knee Exam - PE template opens.
In the Inspection panel, do the following:
1. Click the Gait field and select any of the gait, location, and assisted devices listed in the Gait list.
2. Click the following fields under the Right and/or Left labels and select an option from the corresponding lists:
  - Alignment
  - Atrophy
  - Ecchymosis
  - Effusion
  - Flexibility
  - Maximum Tenderness
  - Skin/Scars
  - Swelling
  For Skin/Scars, select the Normal checkbox if there are no scars.
In the Range of Motion panel, do the following:
1. In the Description section, click the Factors and Description fields under the Right and/or Left text boxes for the following fields and select an option from the corresponding lists:
  - Knee
  - Hip
  - Ankle
  - Lumbar
2. In the Measurement section, click the ROM More Exams link and select an option from the list.
  In this example, the Left Knee Range of Motion - PE template appears.
3. Enter the PE findings in the Range of Motion - Measurement and Range of Motion - Description sections.
4. Click Save & Close.
  Similarly, you can click the ROM Right, ROM Left, Knee Score Right, and Knee Score Left links and document the required details in the respective templates.
5. In the Movement section, click the:
  Flexion and Extension fields to enter information in the corresponding numeric keypad.
  - Right, Left, or Bilateral button in the Default Normal Active Values or Default Normal Passive Values, the respective fields are populated, and the button labels are changed. The Right, Left, or Bilateral button changes to Clear Right, Clear Left, or Clear Bilateral, respectively, in the Range of Motion panel. The Active or Passive buttons are changed to Clear Active or Clear Passive, respectively, in the Right/Left Knee Range of Motion - PE templates.
  Note: To clear the values from specific fields, click the respective clear button.
In the Strength panel, do the following:
1. In the Description section, click the Strength Lower Extremity link.
  The Lower Extremity Strength - PE template opens.
2. Enter the PE findings in the Strength - Description and Strength - Measurement sections.
3. Click Save & Close.
  The data is displayed in the respective fields in the Strength panel.
In the Neurovascular panel, do the following:
1. Click the Neurovascular Lower Extremity link.
  The Neurovascular LE - PE template opens.
2. Enter data in the Description, Measurement, Reflexes, Sensation, and Vascular sections.
3. Click Save & Close.
In the Patella Exam panel, do the following:
1. Click the required options under the Right and/or Left labels for the following fields:
  - Apprehension
  - Q-angle
2. Click the following fields and select an option from the corresponding lists:
  - Crepitation
  - Patella position
  - Tilt
In the Tests panel, click the required options under the Right and/or Left labels for the following fields:
- Lachman's
- McMurray's - lateral
- McMurray's - medial
- Posterior drawer
- Reverse - pivot shift
- Sag sign
- Anterior drawer
- Pivot shift
- Valgus stress
- Varus stress
- Extensor leg
The Functional & Other Tests link displays the Functional & Other Tests PE template to document other tests details.
In the Comments field, enter your comments.
Click Save & Close.

Open the SOAP template.
In the Physical Exam panel, click Knee in the left pane.
The Knee Exam - PE template opens.
In the Inspection panel, do the following:
1. Click the Gait field and select any of the gait, location, and assisted devices listed in the Gait list.
2. Click the following fields under the Right and/or Left labels and select an option from the corresponding lists:
  - Alignment
  - Atrophy
  - Ecchymosis
  - Effusion
  - Flexibility
  - Maximum Tenderness
  - Skin/Scars
  - Swelling
  For Skin/Scars, select the Normal checkbox if there are no scars.
In the Range of Motion panel, do the following:
1. In the Description section, click the Factors and Description fields under the Right and/or Left text boxes for the following fields and select an option from the corresponding lists:
  - Knee
  - Hip
  - Ankle
  - Lumbar
2. In the Measurement section, click the ROM More Exams link and select an option from the list.
  In this example, the Left Knee Range of Motion - PE template appears.
3. Enter the PE findings in the Range of Motion - Measurement and Range of Motion - Description sections.
4. Click Save & Close.
  Similarly, you can click the ROM Right, ROM Left, Knee Score Right, and Knee Score Left links and document the required details in the respective templates.
5. In the Movement section, click the:
  Flexion and Extension fields to enter information in the corresponding numeric keypad.
  - Right, Left, or Bilateral button in the Default Normal Active Values or Default Normal Passive Values, the respective fields are populated, and the button labels are changed. The Right, Left, or Bilateral button changes to Clear Right, Clear Left, or Clear Bilateral, respectively, in the Range of Motion panel. The Active or Passive buttons are changed to Clear Active or Clear Passive, respectively, in the Right/Left Knee Range of Motion - PE templates.
  Note: To clear the values from specific fields, click the respective clear button.
In the Strength panel, do the following:
1. In the Description section, click the Strength Lower Extremity link.
  The Lower Extremity Strength - PE template opens.
2. Enter the PE findings in the Strength - Description and Strength - Measurement sections.
3. Click Save & Close.
  The data is displayed in the respective fields in the Strength panel.
In the Neurovascular panel, do the following:
1. Click the Neurovascular Lower Extremity link.
  The Neurovascular LE - PE template opens.
2. Enter data in the Description, Measurement, Reflexes, Sensation, and Vascular sections.
3. Click Save & Close.
In the Patella Exam panel, do the following:
1. Click the required options under the Right and/or Left labels for the following fields:
  - Apprehension
  - Q-angle
2. Click the following fields and select an option from the corresponding lists:
  - Crepitation
  - Patella position
  - Tilt
In the Tests panel, click the required options under the Right and/or Left labels for the following fields:
- Lachman's
- McMurray's - lateral
- McMurray's - medial
- Posterior drawer
- Reverse - pivot shift
- Sag sign
- Anterior drawer
- Pivot shift
- Valgus stress
- Varus stress
- Extensor leg
The Functional & Other Tests link displays the Functional & Other Tests PE template to document other tests details.
In the Comments field, enter your comments.
Click Save & Close.

Document Abnormal Findings in the Knee

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Document Abnormal Findings in the Knee

Document Abnormal Findings in the Hip

Document Abnormal Findings in the Foot and Ankle

Document Abnormal Findings in the Wrist

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Document Abnormal Findings in the Shoulder

Document Abnormal Findings in the Hand