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 check box 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 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 Wrist 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 Wrist Range of Motion – PE templates.
  Note: To clear the values from specific fields, click the respective clear button.
- Click the Range of Motion Right or Left link, as applicable.
The Right/Left Shoulder Range of Motion - PE template opens. For example, see the Right Shoulder Range of Motion – PE template as follows:
- Enter the PE findings in the Range of Motion - Measurement and Range of Motion - Description sections.
- Click Save & Close.
  The data is displayed in the respective fields in the Measurement section.
If appropriate, click the Cervical Spine Range of Motion link.
The Cervical Spine Range of Motion - PE template appears.
Enter the PE findings in the Range of Motion - Measurement and Range of Motion - Description sections.
Click Save & Close.
In the Strength Tests panel, click the Strength Upper Extremity link.
The Upper Extremity Strength - PE template appears.
Enter the physical exam findings in the Strength - Description and Strength - Measurement sections.
Click Save & Close to display the data in the respective fields under the Description section.
In the Strength Tests section, click the Normal or Abnormal option to indicate the condition of the following:
- External rotation right
- External rotation left
- Shoulder shrug right
- Shoulder shrug left
- Supraspinatus right
- Supraspinatus left
In the Neurovascular panel, click the Neurovascular Upper Extremity link.
The Neurovascular UE- PE template appears.
Enter the PE findings in the Description, Measurement, Reflexes, Sensation, Static Two point Discrimination, Pluses, Vascular Tests, and Neuro Tests sections.
Click Save & Close.
In the Stability/Laxity panel, select the Negative or Positive option of the following fields under the Stability and Laxity labels:
- Anterior apprehension
- Relocation
- Anterior translation
- Posterior translation
- Inferior translation
Select the Negative or Positive option of the following fields under the Biceps tendon label:
- Obrien's
- SLAP test
- Speed's test
- Yergason's
Click the Negative or Positive option of the following fields under the Rotator cuff label:
- Belly press
- Hawkins
- Cross body
- Lift off test
- Neer's
Enter Comments.
Click OK.