Document Abnormal PE Findings in the General Exam

NextGen® Adaptive Content Engine Help Enterprise 8

Document Abnormal Findings in the Knee

Open the SOAP template. In the Physical Exam panel, click Knee in the left pane. The Knee Exam - PE template opens. In the Inspection panel, do the following: Click the Gait field and select any of the gait, location, and assisted devices listed in the Gait list. Click the following fields under the Right and/or Left labels and select an option from the corresponding lists: Alignment Atrophy Ecchymosis Effusion Flexibility Maximum Tenderness Skin/Scars Swelling For Skin/Scars, select the Normal check box if there are no scars. In the Range of Motion panel, do the following: In the Description section, click the Factors and Description fields under the Right and/or Left text boxes for the following fields and select an option from the corresponding lists: Knee Hip Ankle Lumbar In the Measurement section, click the ROM More Exams link and select an option from the list. In this example, the Left Knee Range of Motion - PE template appears. Left Knee Range of Motion - PE Enter the PE findi

NextGen® Adaptive Content Engine Help Enterprise 8

Document Abnormal Findings in the Elbow

Open the SOAP template. In the Physical Exam panel, click Elbow in the left pane. The Elbow - PE template opens. Note: If the Elbow option is not available in the left pane, click Additional and select Elbow. Note: You can also document the physical exam findings directly in the available fields in each panel instead of using the links in the panels. 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. 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. In the Range of Motion panel, Description section, click the Factors and Description fields under Right and/or Left labels

NextGen® Adaptive Content Engine Help Enterprise 8

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. Open the SOAP template. In the Physical Exam panel, click Hip in the left pane. The Hip Exam - PE template opens. 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. 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 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

NextGen® Adaptive Content Engine Help Enterprise 8

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 corres

NextGen® Adaptive Content Engine Help Enterprise 8

Document Abnormal Findings in the Wrist

Open the SOAP template. In the Physical Exam panel, click Wrist in the left pane. The Wrist - PE template opens. 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 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. 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. If the findings are within a normal range, select the Normal option. 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 Defau

NextGen® Adaptive Content Engine Help Enterprise 8

Document the Abnormal Thoracic Spine Exam Findings

Access the Thoracic Spine Exam - PE template. In the Inspection panel, do the following: Select whether the Posture is Symmetrical or Asymmetrical. In the Posture section, click the text field to select a deformity from the Deformity list. In the Posture section, click the Detail link and select an appropriate option from the Spine Inspection - PE window. Enter the details of Atrophy, Crepitus, Apprehension, Ecchymosis, Maximum tenderness, and Skin/scars by selecting the desired option. In the Range of Motion section, do the following: In the Description section, select if the condition is Active or Passive. In the Measurement section, document the details of the Thoracic, Shoulder, Elbow, and Wrist regions. Document the desired details in the Range of Motion - Measurement and Range of Motion - Description sections. Click Save & Close. In the Strength panel, click the Strength Upper Extremity link, and then do the following: In the Strength Upper Extremity - PE template, enter the find

Document Abnormal PE Findings in the General Exam - PE Template

Recommendations

Document Abnormal Findings in the Knee

Document Abnormal Findings in the Elbow

Document Abnormal Findings in the Hip

Document Abnormal Findings in the Shoulder

Document Abnormal Findings in the Wrist

Document the Abnormal Thoracic Spine Exam Findings

Document Abnormal Findings in the Knee

Document Abnormal Findings in the Elbow

Document Abnormal Findings in the Hip

Document Abnormal Findings in the Shoulder

Document Abnormal Findings in the Wrist

Document the Abnormal Thoracic Spine Exam Findings