Documenting a Physical Exam

NextGen® Adaptive Content Engine Help Enterprise 8

Document an Exam with the Quick Exam Defaults

In the Physical Exampanel of the Objective template, click the One Page Exam link in the left pane to open the General Exam PT – PE template. On the General Exam PT – PE template, click the Location field at the top and then select a location. If a location is not listed, select the top blank line, and type the location. On the any exam template, select the Right or Left check box to indicate the side of the body. Click the Quick Exams field to open the DB picklist. Review defaulted values and update values where needed. For information on how to create or modify template defaults, go to NextGen Healthcare Success Community and download the latest Template Defaults Setup System Template for NextGen® Adaptive Content Engine. 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

Document a Physical Exam

The One Page Exam template is used to document a physical exam. Physical Exam panel You can examine a patient and document the information in the Physical Exam panel on the SOAP template. In the Physical Exam panel, you can, Use the One Page Exam to document the exam on the Gyn-PE template. On the Gyn-PE select the Normal check box to indicate normal findings for each system or click the Findings field to add any abnormal findings. Use other single system exam and its submenu in the left pane to document the corresponding exam details. When you click the single system exam or its submenu, the respective template opens. Use the Office Diagnostics button to document or review diagnostics and to place orders for the tests. Use the Quick Load or Quick Save button to load a saved default set or save a new default set. Use the Physical Exam History button to copy previous physical exam records to the current encounter. Document a Breast Palpation Physical Exam You can document the breast pal

NextGen® Adaptive Content Engine Help Enterprise 8

Document Physical Exam Findings

You can document the complete physical examination details of a patient on the SOAP template. The One Page Exam link opens a gender-specific or a gender-neutral, one-page physical exam template. Based on the configuration in the Physical Exam panel of the Framework Content system template and the selection of the Enable Gender Neutral PE check box on the Practice Configuration template, the gender-specific or a gender-neutral, one-page physical exam template opens. For more information, go to NextGen Healthcare Success Community, and download the latest Framework Content System Template forNextGen®Adaptive Content Engine and Practice Configuration Template User Guide forNextGen®Adaptive Content Engine. Open NextGen® Enterprise EHR. On the SOAP template, expand the Physical Exam panel. Select One Page Exam. The One Page - Physical Exam template opens. One Page - Physical Exam Document your findings on the template. Note: To save the documented value as the default set, you can select th

NextGen® Adaptive Content Engine Help Enterprise 8

Document Abnormal PE Findings in the General Exam - PE Template

Open the SOAP template. In the Physical Exam panel, click One Page Exam in the left pane. The General Exam - PE template opens. In the Inspection panel, click the Gait field to select any of the gait, location, weight bearing, and assistive devices listed. Click the following fields under the Right and/or Left labels and select a condition from the corresponding lists: Deformity Ecchymosis Skin/scars Skin/scars Swelling 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, do one of the following to document range of motion: Click the Multiple Range of Motion Exams link to open the ROM - PE Range of Motion To launch the system-specific Range of Motion - PE template, click the system-specific links listed under Right and Left fields. Enter the scores in the Right and Left fields. The Knee Score Right and Knee Score Left links are used to gen

NextGen® Adaptive Content Engine Help Enterprise 8

Orthopedic Physical Exam Templates

Providers can document physical exam findings on the SOAP template. You can find the list of physical exams for Orthopedics, in the left pane of Physical Exam panel. Physical Exam The physical exams listed in the left pane enables you to open the corresponding physical exam template. All the resulting physical exam templates enable you to open the other system-specific templates by clicking the links in the left pane. Document a Multi System Orthopedic Exam You can document a multi system exam on the General Exam - PE template. Open the Physical Exam Templates You can open the physical exam template to document the normal and abnormal physical exam details. Document Abnormal PE Findings in the General Exam - PE Template Document the Musculoskeletal Physical Exam Findings You can document the Musculoskeletal physical exam findings in the Musculoskeletal section. Document Normal Cervical Spine Exam Findings Document the Abnormal Cervical Spine Exam Findings You can document the abnormal

Documenting a Physical Exam

Recommendations

Document an Exam with the Quick Exam Defaults

Enter Exam Findings for Strength

Document a Physical Exam

Document Physical Exam Findings

Document Abnormal PE Findings in the General Exam - PE Template

Orthopedic Physical Exam Templates

Document an Exam with the Quick Exam Defaults

Enter Exam Findings for Strength

Document a Physical Exam

Document Physical Exam Findings

Document Abnormal PE Findings in the General Exam - PE Template

Orthopedic Physical Exam Templates