NextGen Knowledge Center

Document Abnormal Findings in the Foot and Ankle

  1. Open the SOAP template.
  2. In the Physical Exam panel, click Foot/Ankle in the left pane.
    The Foot/Ankle Exam - PE template opens.
  3. 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
  4. 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
  5. 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 check box.

  6. 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 vice versa.

  7. In the Range of Motion panel, Description section, click the Factors and Description fields under the Right or Left labels and select an option from the corresponding lists:
    If the PE findings are normal, select the Normal active and Normal passive option under the Right and/or Left labels.
  8. 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 Ankle Range of Motion - PE templates.
      • 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 Ankle Range of Motion - PE templates.
      Range of Motion

    • click the Range of Motion Right or Left link, as applicable.
    The Right/Left Ankle Range of Motion - PE template appears. For example, see the Right Ankle Range of Motion – PE template as follows.
    Right Ankle Range of Motion – PE

  9. Enter the PE findings in the Range of Motion - Measurement and Range of Motion - Description sections.
  10. Click Save & Close.
    The data is displayed in the respective fields in the Measurement section.
  11. If applicable, click the Range of Motion Left link to document the findings on the Left Ankle Range of Motion -PE template.
  12. In the Strength panel, Description section, click the Strength Lower Extremity link.
    The Lower Extremity Strength - PE template appears.

    Any data populated earlier is displayed in the Lower Extremity Strength - PE template.

  13. Enter the PE findings in the Strength - Description and Strength - Measurement sections.
  14. Click Save & Close.
  15. In the Neurovascular panel, click the Neurovascular Lower Extremity link.
    The Neurovascular LE - PE template appears.
  16. Enter data in the Description, Measurement, Reflexes, Sensation, and Vascular sections.
  17. Click Save & Close.
  18. In the Stability panel, click the following fields under the Right and/or Left labels and select an option from the corresponding lists:
    • Location
    • Inspection
    • Stability
  19. In the Tests panel, click the required options under the Right and/or Left labels for the following fields:
    • External rotation
    • Flexor hallucis longus triggering
    • Midfoot compression
    • MTP Lachman's
    • Peroneal subluxation
    • Single toe raise
    • Thompson's
    • Anterior drawer
    • Talar tilt
    • Subtalar tilt
    • Mulder's test right
    • Mulder's test left
  20. In the Other exams section, click the Type field and select an option from the corresponding lists.
    The Additional Tests link displays the Additional Test template to enter other tests details. The Diabetic Foot Exam link is used to document PE findings of the diabetic patients.
  21. In the Comments field, enter your comments and click OK.