Document the Abnormal Lumbar Spine Exam Findings

You can document the abnormal lumbar spine exam findings in the Lumbar Spine Exam - PE template.

1. Open the PE - Lumbar Spine Exam template.
2. Expand the Inspection panel.
3. In the Posture field, do the following:
   1. Select whether the Posture is Symmetrical or Asymmetrical.
   2. Click the text field to select a deformity from the Deformity list.
   3. Click the Detail link to select an appropriate option from the Spine Inspection - PE window.
4. Expand the Range of Motion panel, and then do the following:
   1. To select an option from the corresponding lists, in the Description section, in the Factors and Description fields, click the fields in the Right and Left labels.
   2. If the physical exam findings are normal, select the Normal checkbox in the Factors and Description fields.
   3. Click the Goniometer link in the Measurement section.
      The Lumbar 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 in the panels.
   4. Enter the PE findings in the Range of Motion - Measurement and Range of Motion - Description sections.
   5. Click Save & Close to fill the respective fields under the Lumbar section.
   6. Click the Right Hip Range of Motion link.
   7. Enter the findings in the Range of Motion - Measurement and Range of Motion - Description sections.
   8. Click Save & Close.
   9. Follow the same steps for the Left Hip Range of Motion.
5. In the Comments field, enter additional information, if necessary.
6. In the Test panel, in the Additional Exam and Findings section, select the desired Exam, Findings and Additional Findings details by clicking the respective fields.
   1. To add the Exam, Findings and Additional Findings, click Add.
   2. To modify the Exam, Findings and Additional Findings, click Update.
   3. To clear the selected Exam, Findings and Additional Findings, click Clear.
   4. To remove the existing record from the grid, select the entry from the grid, and then click Remove.
      Note: You can configure the additional exam findings using the ortho_additional_exam and ortho_additional_finding Custom DB Picklists template.
7. Click OK.