Document the Abnormal Cervical Spine Exam Findings

You can document the abnormal cervical spine exam findings in the Cervical Spine Exam - PE template.

1. Open the Cervical Spine Exam - PE template.
2. Expand the Inspection panel.
3. In the Posture section, do the following:
   1. Click the text field to select an appropriate deformity from the Deformity list.
   2. Click the Detail link to select a desired option from the Spine Inspection - PE window.
4. Expand the Range of Motion panel, and then do the following:
   1. In the Description section, click the Factors and Description fields to select an option from the corresponding lists.
   2. In the Measurement section, click the Goniometer link to document the details for a range of motion.
      The Cervical Spine Range of Motion - PE template opens.

      Note: You can also document the physical exam findings directly in the available fields in each panel instead of using the links to open the templates.
   3. Enter the physical exam findings in the Range of Motion - Measurement and Range of Motion - Description sections.
   4. Click Save & Close.
      The data appears in the respective fields in the Cervical label of the Measurement section in the Cervical Spine Exam - PE template.
5. In the Shoulder section, click the Right Shoulder Range of Motion link, and then do the following:
   1. Enter the physical exam findings in the Range of Motion - Measurement and Range of Motion - Description sections.
   2. Click Save & Close.
      The data appears in the respective fields in the Shoulder label in the Measurement section.
6. Click the Left Shoulder Range of Motion link, and then do the following:
   1. Enter the physical exam findings in the Range of Motion - Measurement section.
   2. Enter the physical exam findings in the Range of Motion - Description section.
7. Expand the Strength panel, and then do the following:
   1. Click the Strength Upper Extremity link.
   2. Enter the PE findings in the Strength - Description and Strength - Measurement sections.
   3. Click OK.
8. Expand the Neurovascular panel, and then do the following:
   1. Click the Neurovascular Upper Extremity link.
   2. In the Neurovascular UE - PE template, enter the findings in the Description, Measurement, Reflexes, Sensation, Static Two point Discrimination, Pluses, Vascular Tests, and Neuro Tests sections.
   3. Click Save & Close.
      The details appear in the respective fields in the Neurovascular panel.
9. In the Sensory panel, click the Decreased or Increased option under the Right or Left labels for each item.
10. If the findings are normal, select the All Normal check box.
11. In the Test panel, select the positive or negative option for the following fields:
    • Axial compression
    • Distraction test
    • Quadrant position
12. In the Test panel, in the Additional Exam and Findings section, select the desired Exam, Findings and Additional Findings details by clicking the respective fields.
    1. To add the Exam, Findings and Additional Findings, click Add.
    2. To modify the Exam, Findings and Additional Findings, click Update.
    3. To clear the selected Exam, Findings and Additional Findings, click Clear.
    4. To remove the existing record from the grid, select the entry from the grid, and then click Remove.
       Note: You can configure the additional exam findings using the ortho_additional_exam and ortho_additional_finding Custom DB Picklists template.

       

13. In the Comments field, enter your comments, if any.
14. Click OK.