Document Observations

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Inspection/Palpation

The Inspection/Palpation panel is where descriptions of findings based on visual inspection and by palpation are documented for things such as crepitus, edema, temperature, deformities, skin and scars, masses and tenderness. Inspection/Palpation For panels that contain Normal check boxes, select the Normal check boxes to indicate that exam findings are normal. For panels with right and left sides, enter the exam findings for right side first. Click each field and select from the corresponding picklist. If left side findings are the same as the right side, click the corresponding double-arrow button to copy the findings from the right side to the left side. If left side findings are different from right side findings, click in the corresponding left side field and select from the list that appears. Repeat for all locations as appropriate. Click the Comments field to type comments or use the My Phrases link to enter comments. Parent topic: Documenting a Physical Exam

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Exam Findings for Strength

The Strength panel is where strength findings are documented. The body region of the exam template determines the links that appear in the Strength panel that enable you to document strength findings for additional locations and motor tests. Strength On the General Exam PT - PE template, click a link in Strength panel to open a detailed strength physical exam template. Click Save & Close when you have finished documenting on the template. In the top section, document normal strength for the region by selecting one of the available options for Lower extremity strength normal and Upper extremity strength normal. To document that the strength is normal except for something: Select the except for checkbox. Click the corresponding field and select from the multi-select picklist. If applicable, select the top blank line from the picklist to type a value that is not in the picklist. After making selections, click Close to exit the picklist. Note: Panels on region specific physical exam templa

NextGen® Adaptive Content Engine Help Enterprise 8

Documenting a Physical Exam

Documenting a physical exam for Physical Therapy involves using exam templates that focus in detail on a specific body part, such as an upper extremity (hand) or a region (lumbar region of the spine). Physical exam templates enable you to document bilateral physical findings. For a general exam, you can use the one-page General Exam PT - PE template. Use the Physical Therapy specialty one-page General Exam PT - PE template to document a body part or region that does not have a detailed template. Use the Quick Save template defaults to document exam finding and to make changes to populated findings. The fields that appear on each panel depend on which physical exam template you have open and the region of the body you are documenting. Ensure that you complete all required fields in the physical exam templates. Document an Exam with the Quick Exam Defaults Document Observations Enter Inspection/Palpation Record a Range of Motion Findings Enter Exam Findings for Strength Record Neurovascu

NextGen® Adaptive Content Engine Help Enterprise 8

Document Normal Findings in the Hand

Open the SOAP template. In the Physical Exam panel, click Hand in the left pane. The right and left options appear in the sub-menu. Click right to open the Hand Right - PE template or click left to open the Hand Left - PE template. Hand Right - PE If appropriate, click the Quick Exams field and select Normal from the list. The respective fields in the Hand Right - PE template are filled with the normal values. Select the diagnosis codes from the Dx1 or Dx2 fields. You can enter two diagnosis codes for this physical exam. Click the corresponding Status field to select the status of diagnosis. Click OK. Parent topic: Orthopedic Physical Exam Templates

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 the Musculoskeletal Physical Exam Findings

You can document the Musculoskeletal physical exam findings in the Musculoskeletal section. Open the Musculoskeletal - Physical Exam template. Musculoskeletal - Physical Exam If all parameters in the musculoskeletal physical exam are normal, click the Select all normal check box. Note: You can also individually select the Normal check box for each paramaeter. Click the fields in Extremities overview and Gait, and select the desired options. In the Posture field, do the following: Click the field to choose a desired option from the Deformity list. Click the Detail link and select the desired options in the Spine Inspection - PE template. Click Save & Close. Your selection is updated in the respective fields. In the Cervical spine section, click the field in the Inspection/palpation field. The CERVICAL SPINE - INSPECTION/PALPATION window opens. Do the following in the CERVICAL SPINE - INSPECTION/PALPATION window: To enter the Cervical spine segment details, select a desired option from t

Document Observations

Recommendations

Enter Inspection/Palpation

Enter Exam Findings for Strength

Documenting a Physical Exam

Document Normal Findings in the Hand

Document Abnormal Findings in the Shoulder

Document the Musculoskeletal Physical Exam Findings

Enter Inspection/Palpation

Enter Exam Findings for Strength

Documenting a Physical Exam

Document Normal Findings in the Hand

Document Abnormal Findings in the Shoulder

Document the Musculoskeletal Physical Exam Findings