NextGen Knowledge Center

Document Abnormal Findings in the Wrist

  1. Open the SOAP template.
  2. In the Physical Exam panel, click Wrist in the left pane.
    The Wrist - PE template opens.
  3. In the Inspection panel, Right and Left sections, select the required options for the following fields:
    • Crepitus
    • Edema
    • Atrophy
    • Deformities
    • Ecchymosis
    • Mass
    • Skin/scars - select Normal if there are no scars
  4. In the Palpation section, click the Maximum tenderness field and select the required option from the corresponding list.
    The double-arrow 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 the Right and/or Left labels and select an option from the corresponding list.
  6. If the findings are within a normal range, select the Normal option.
  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 Range of Motion Right and Left links.
      • 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 Wrist Range of Motion - PE templates.
    • Click the Range of Motion Right or Left link, as applicable.

      The Right/Left Shoulder Range of Motion - PE template appears. For example, see the Right Shoulder Range of Motion – PE template as follows:

      Right Wrist 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 Wrist Range of Motion - PE template.
  8. In the Strength panel, Description section, click the Strength Upper Extremity link.
    The Upper 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 Measurement section, click the following fields under the Right or Left and select an option from the corresponding lists:
    • Abductor pollicis brevis
    • Abduction, finger
    • Abduction, finger
    • First dorsal interossei
  12. In the Grip Strength section, click the required fields and options under the Right or Left labels to indicate the grip strength.
    • Froment's
    • Pinch
    • Grip
  13. In the Neurovascular panel, Description section, click the Neurovascular Upper Extremity link.
    The Neurovascular UE - PE template appears.
  14. Enter data in the Description, Measurement, Reflexes, Sensation, Static Two Point Discrimination, Pluses, Vascular Tests, and Neuro Tests sections.
  15. Click Save & Close.
  16. In the Measurement section, select the required options in the following fields under the Right or Left labels.
    • Median nerve compression
    • Phalen's
    • Allen's
    • Tinel's
    • Two-point discrimination
  17. In the Stability panel, click the required options of the following fields under the Right or Left labels:
    • Catch-up clunk
    • ECU instability
    • LT ballotment
    • Mid-carpal shift
    • Varus stress
    • Valgus stress
    • Watson's
    • DRUJ right
    • DRUJ left
  18. In the Tests panel, click the following fields under the Right and/or Left labels:
    • Basal Joint Grind
    • Finkelstein's
  19. Enter any additional information in the Comments field.
  20. Click OK.