Record a Range of Motion Findings

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 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

Document Knee Score

In the Range of Motion panel on the General Exam PT - PE template, click the Knee Score Right or the Knee Score Left link to document the knee score. The corresponding Knee Score Right – PE or Knee Score Left – PE template opens. Select findings for Pain, Stability, Range of Motion, and Deductions. The Knee Score calculates automatically. Knee Score Left - PE Click Save & Close when done. Parent topic: Record a Range of Motion Findings

NextGen® Adaptive Content Engine Help Enterprise 8

Document Knee Function Score

To document the Knee Function Score, click the Function Score link on the Knee Score physical exam template. The Knee Function Score – PE template opens. Knee Function Score - PE Select function options for Walking, Stairs, and Deductions. The Function Score calculates automatically. Click Save & Close. The Knee Score template opens. Click Save & Close on the Knee Score physical exam template to return to the General Exam PT - PE template. Parent topic: Record a Range of Motion Findings

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 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

Record a Range of Motion Findings

Recommendations

Enter Exam Findings for Strength

Document an Exam with the Quick Exam Defaults

Document Knee Score

Document Knee Function Score

Documenting a Physical Exam

Document Abnormal Findings in the Knee

Enter Exam Findings for Strength

Document an Exam with the Quick Exam Defaults

Document Knee Score

Document Knee Function Score

Documenting a Physical Exam

Document Abnormal Findings in the Knee