Document the Musculoskeletal Physical Exam Findings

You can document the Musculoskeletal physical exam findings in the Musculoskeletal section.

1. Open the Musculoskeletal - Physical Exam template.
   

2. 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.
3. Click the fields in Extremities overview and Gait, and select the desired options.
4. In the Posture field, do the following:
   1. Click the field to choose a desired option from the Deformity list.
   2. Click the Detail link and select the desired options in the Spine Inspection - PE template.
   3. Click Save & Close.
      Your selection is updated in the respective fields.
5. In the Cervical spine section, click the field in the Inspection/palpation field.
   The CERVICAL SPINE - INSPECTION/PALPATION window opens.
6. Do the following in the CERVICAL SPINE - INSPECTION/PALPATION window:
   1. To enter the Cervical spine segment details, select a desired option from the CERVICAL SEGMENTS section.
      

   2. To enter the severity of the problem, select the desired option from the SEVERITY section.
   3. To select the findings, select the desired option from the FINDING section.
   4. Click Close.
   5. To enter the range of motion, click the field in the Range of motion and select the desired option.
   6. Click the Detail link and document the desired details.
7. Repeat the same steps to document other sections such as the Thoracic spine, Lumbar spine, Shoulder, Elbow, Hands, Hip, Ribs, Pelvis, Knee, and Foot/ankle.
8. In the Comments field, enter any additional information.
9. Click Save & Close.