NextGen Knowledge Center

Document Abnormal Findings in the Elbow

  1. Open the SOAP template.
  2. In the Physical Exam panel, click Elbow in the left pane.
    The Elbow - PE template opens.
  3. 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.
  4. 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 check box if there are no scars.

    The icon is used to copy the selected item from the Right field to Left field and vice versa.

  5. In the Range of Motion panel, Description section, click the Factors and Description fields under Right and/or Left labels and select an option from the corresponding lists.
  6. If the PE findings are normal, select the Normal check boxes.
  7. To document the physical exam findings in the Measurement section, do one of the following:
    • Enter values in the displayed fields using the corresponding numeric keypad.
    • In Default Normal Active Values or Default Normal Passive Values, click the Right, Left, or Bilateral button:
      • the respective fields are populated in the Range of Motion panel and Right/Left Elbow Range of Motion – PE templates.
      • the Right, Left, or Bilateral buttons change to Clear Right, Clear Left, or Clear Bilateral, respectively, in the Range of Motion panel.
      • the Active or Passive buttons change to Clear Active or Clear Passive, respectively, in the Right/Left Elbow Range of Motion – PE templates.
  8. Click the Right Elbow Range of Motion or Left Elbow Range of Motion link, as required.
    The Right/Left Elbow Range of Motion - PE template appears. For example, see the Right Elbow Range of Motion - PE template as follows:
    Right/Left Elbow Range of Motion - PE

    1. Enter the PE findings in the Range of Motion - Measurement and Range of Motion - Description sections.
    2. Click Save & Close to populate the respective fields in the Measurement section.
    3. Similarly, click the Left Elbow Range of Motion link and document the PE findings, if any, in the Left Elbow Range of Motion -PE template.
  9. In the Strength panel, click the Strength Upper Extremity link.
    The Upper Extremity Strength - PE template appears.
  10. Enter the PE findings in the Strength - Description and Strength - Measurement sections.
  11. Click Save & Close.
  12. In the Neurovascular panel, click the Neurovascular Upper Extremity link.
    The Neurovascular UE - PE template appears.
  13. Enter data in the Description, Measurement, Reflexes, Sensation, Static Two Point Discrimination Pluses, Vascular Tests, and Neuro Tests sections.
  14. Click Save & Close.
  15. In the Stability/Laxity Tests panel, select the required options in Left or Right sections for Laxity valgus, Laxity varus, Laxity posterolateral, Cozen's tests and Elbow Flexion.
  16. Click the required options for Golfer's elbow, Grip strength, Lateral epicondylitis, Medial epicondylitis, Tinel's sign, Mill's tests, Valgus stress, and Varus stress.
  17. In the Comments field, enter your comments and then click OK.