NextGen Knowledge Center

Document Abnormal Findings in the Hip

In the Inspection panel, click the Gait field to select any of the gait, location, and assisted devices available in the list.

  1. Open the SOAP template.
  2. In the Physical Exam panel, click Hip in the left pane.
    The Hip Exam - PE template opens.
  3. In the Inspection panel, click the following fields under the Right and Left labels and select an option from the corresponding lists:
    • Alignment
    • Ecchymosis
    • Effusion
    • Flexibility
    • Skin/Scars - select the Normal check box if there are no scars
    • Swelling
    The double-arrow icon is used to copy the selected item from the Right field to Left field and vice versa.
  4. In the Range of Motion panel, Description section, click the Factors and Description fields under the Right or Left labels for the following fields and select an option from the corresponding lists:
    • Hip
    • Knee
    • Lumbar
  5. If the PE findings are normal, select the Normal check box for the above fields.
  6. 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 Hip 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 Hip Range of Motion - PE templates.
  7. Click the Range of Motion Right or Left link, as applicable.
    The Right/Left Hip Range of Motion - PE template appears. For example, see the Right Hip Range of Motion – PE template as follows:
    Right Hip 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.
      The data is displayed in the respective fields in the Measurement section.
    3. If applicable, click the Range of Motion Left link to document the findings on the Left Hip Range of Motion - PE template.
    4. If applicable, click the Range of Motion More Exams link to select more exams from the Rom More Exam lists.
  8. In the Strength panel, Description section, click the Strength Lower Extremity link.
    The Lower Extremity Strength - PE template appears.
  9. Enter the PE findings in the Strength - Description and Strength - Measurement sections.
  10. Click Save & Close.
  11. In the Neurovascular panel, click the Neurovascular Lower Extremity link.
    The Neurovascular LE - PE template appears.
  12. Enter data in the Description, Measurement, Reflexes, Sensation, and Vascular Tests sections.
  13. Click Save & Close.
  14. In the Tests panel, click the required options under the Right and/or Left labels for the following fields:
    • Faber's
    • Ober's
    • Thomas
    • Apparent leg length
    • Piriformis stretching
    • Stork
    • Trendelenburg's
  15. Click the True leg length field to select an option from the list.
  16. In the Comments field, enter additional comments.
  17. Click OK to populate the data in the grid on the Physical Exam panel.