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Document Abnormal PE Findings in the General Exam - PE Template
Open the
SOAP
template.
In the
Physical Exam
panel, click
One Page Exam
in the left pane.
The
General Exam - PE
template opens.
In the
Inspection
panel, click the
Gait
field to select any of the gait, location, weight bearing, and assistive devices listed.
Click the following fields under the
Right
and/or
Left
labels and select a condition from the corresponding lists:
Deformity
Ecchymosis
Skin/scars
Skin/scars
Swelling
Tenderness
For
Skin/scars
, select the
Normal
checkbox if there are no scars.
The
icon is used to copy the selected item from the
Right
field to
Left
field and vice versa.
In the
Range of Motion
panel, do one of the following to document range of motion:
Click the
Multiple Range of Motion Exams
link to open the
ROM - PE
To launch the system-specific
Range of Motion - PE
template, click the system-specific links listed under
Right
and
Left
fields.
To document lower and upper extremity strength in the
Strength
panel, click the
Strength Lower Extremity
and
Upper Extremity Strength - PE
links.
The
Motor and More Tests
links displays the
Lumbar Motor Function - PE
template to document physical exam findings of Lumbar and other tests.
To document neurovascular findings for the extremities, do one of the following:
Click the
Neurovascular Lower Extremity
and
Neurovascular Lower Extremity
links to document a complete exam.
To document a normal exam, click the
Lower extremity neurovascular normal
and the
Upper extremity neurovascular
normal.
In the
Comments
field, enter your comments.
Click
OK
.
The entered data is displayed in the grid on the
Physical Exam
panel.
Document Abnormal PE Findings in the General Exam - PE Template
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Abnormal Findings in the Elbow
Open the SOAP template. In the Physical Exam panel, click Elbow in the left pane.The Elbow - PE template opens. Note: If the Elbow option is not available in the left pane, click Additional and select Elbow. Note: You can also document the physical exam findings directly in the available fields in each panel instead of using the links in the panels. Click the Dx 1 or Dx 2 field and select the patient's diagnosis and then click the corresponding Status field to select the status of the diagnosis. In the Inspection panel, click the following fields under the Right and/or Left labels and select an option from the corresponding lists: Bursa Deformities Ecchymosis Effusion Skin/scars Swelling Maximum tenderness For Skin/Scars select the Normal checkbox if there are no scars. The icon is used to copy the selected item from the Right field to Left field and vice versa. In the Range of Motion panel, Description section, click the Factors and Description fields under Right and/or Left labels an
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
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: Click the Gait field and select any of the gait, location, and assisted devices listed in the Gait list. 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: 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 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. Left Knee Range of Motion - PE Enter the PE findings
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Abnormal Findings in the Hand
Open the SOAP template. In the Physical Exam panel, click Hand in the left pane.The right and left options appear in the sub-menu. Click right to open the Hand Right - PE template or click left to open the Hand Left - PE template. 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. 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 Note: For Skin/Scars and Laxity/stability, select the Normal option if there are no scars. If the PE findings are normal, select the All normal checkbox. 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
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document the Abnormal Cervical Spine Exam Findings
You can document the abnormal cervical spine exam findings in the Cervical Spine Exam - PE template. Open the Cervical Spine Exam - PE template. Expand the Inspection panel. In the Posture section, do the following: Click the text field to select an appropriate deformity from the Deformity list. Click the Detail link to select a desired option from the Spine Inspection - PE window. Expand the Range of Motion panel, and then do the following: In the Description section, click the Factors and Description fields to select an option from the corresponding lists. In the Measurement section, click the Goniometer link to document the details for a range of motion.The Cervical Spine Range of Motion - PE template opens. Note: You can also document the physical exam findings directly in the available fields in each panel instead of using the links to open the templates. Enter the physical exam findings in the Range of Motion - Measurement and Range of Motion - Description sections. Click Save &
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Abnormal Findings in the Foot and Ankle
Open the SOAP template. In the Physical Exam panel, click Foot/Ankle in the left pane.The Foot/Ankle Exam - PE template opens. In the Inspection panel, Ambulation section, click the following fields to select an option from the corresponding list: Gait Gait Location Weight Bearing Weight Bearing Location Assistance In the Alignment section, click the following fields under the Right and/or Left labels and select an option from the corresponding lists: Hindfoot Midfoot Forefoot Toes In the Skin section, click the following fields under the Right or Left labels and select an option from the corresponding lists: Ecchymosis Hyperhidrosis Inflammation Lesion Swelling Wound If the PE findings are normal, select the Normal checkbox. In the Tenderness section, click the following fields under the Right and/or Left labels and select an option from the corresponding list: Primary Secondary Tinel Other The double-arrow icon is used to copy the selected item from the Right field to Left field and
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Abnormal Findings in the Shoulder
Open the SOAP template. In the Physical Exam panel, click Shoulder in the left pane.The Shoulder - PE template opens. In the Inspection panel, click the appropriate options for the following fields under the Right and Left labels: Atrophy Deformities Posture Rhythm Crepitus Click the following fields under the Right and/or Left labels to select a condition from the corresponding lists: Ecchymosis Position Skin/scars Tenderness The double-arrow icon is used to copy the selected item from the Right field to Left field and vice versa. In the Range of Motion panel, Description section, click the Factors and Description fields for the following fields under the Right and Left labels to enter an option from the corresponding lists: Shoulder Elbow Wrist Cervical Lumbar If the PE findings are normal, select the Normal checkbox for the above fields. To document the physical exam findings in the Measurement section, do one of the following: Enter values in the displayed fields using the correspo
