Orthopedic Physical Exam Templates

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

Document Normal Lumbar Spine Exam Findings

Open the SOAP template. In the Physical Exam panel, click Lumbar spine in the left pane. The PE - Lumbar Spine Exam template opens. PE - Lumbar Spine Exam Click the Quick exams field and select Normal. The respective fields in the PE - Lumbar Spine Exam template are populated with the normal values. Select the diagnosis codes from the Dx1 or Dx2 fields. Two diagnosis codes can be entered for this physical exam. Click the corresponding Status field to select the status of each diagnosis. Click OK. Parent topic: Orthopedic Physical Exam Templates

NextGen® Adaptive Content Engine Help Enterprise 8

Document the Abnormal Lumbar Spine Exam Findings

You can document the abnormal lumbar spine exam findings in the Lumbar Spine Exam - PE template. Open the PE - Lumbar Spine Exam template. Expand the Inspection panel. In the Posture field, do the following: Select whether the Posture is Symmetrical or Asymmetrical. Click the text field to select a deformity from the Deformity list. Click the Detail link to select an appropriate option from the Spine Inspection - PE window. Expand the Range of Motion panel, and then do the following: To select an option from the corresponding lists, in the Description section, in the Factors and Description fields, click the fields in the Right and Left labels. If the physical exam findings are normal, select the Normal check box in the Factors and Description fields. Click the Goniometer link in the Measurement section. The Lumbar Spine Range of Motion - PE template opens. Lumbar Spine Range of Motion - PE Note: You can also document the physical exam findings directly in the available fields in each

NextGen® Adaptive Content Engine Help Enterprise 8

Document a Multi System Orthopedic Exam

Open the SOAP template. In the Physical Exam panel, click One Page Exam in the left pane. The General Exam - PE template opens. In Location, click the region of injury from the Ort Regions list. In Quick exams, select the appropriate check boxes and click the corresponding field to display the Td Dbp Filter list. Select Normal from the Td Dbp Filter list. The respective fields in the General Exam - PE template are filled with the normal values. Select the diagnosis codes in the Dx1 or Dx2 fields. Click the corresponding Status field to select the status of each diagnosis. Click OK. View the Last Physical Exam You can view the last physical exam findings for Orthopedic patients from the General Exam - PE template. Parent topic: Orthopedic Physical Exam Templates

NextGen® Adaptive Content Engine Help Enterprise 8

Document the Abnormal Thoracic Spine Exam Findings

Access the Thoracic Spine Exam - PE template. In the Inspection panel, do the following: Select whether the Posture is Symmetrical or Asymmetrical. In the Posture section, click the text field to select a deformity from the Deformity list. In the Posture section, click the Detail link and select an appropriate option from the Spine Inspection - PE window. Enter the details of Atrophy, Crepitus, Apprehension, Ecchymosis, Maximum tenderness, and Skin/scars by selecting the desired option. In the Range of Motion section, do the following: In the Description section, select if the condition is Active or Passive. In the Measurement section, document the details of the Thoracic, Shoulder, Elbow, and Wrist regions. Document the desired details in the Range of Motion - Measurement and Range of Motion - Description sections. Click Save & Close. In the Strength panel, click the Strength Upper Extremity link, and then do the following: In the Strength Upper Extremity - PE template, enter the find

NextGen® Adaptive Content Engine Help Enterprise 8

Document Normal Findings for the Shoulder

Open the SOAP template. In the Physical Exam panel, click Shoulder in the left pane. The Shoulder - PE template opens. Shoulder - PE In the Quick exams field, select the appropriate check boxes and click the corresponding field to display the list. If appropriate, select Normal from the list. The respective fields in the Shoulder - PE template populate with the normal values. Enter diagnosis codes in Dx1 or Dx2. Two diagnosis codes can be entered for this physical exam. Click the corresponding Status field to select the status for each diagnosis. Click OK. Parent topic: Orthopedic Physical Exam Templates

Orthopedic Physical Exam Templates

Recommendations

Document Abnormal PE Findings in the General Exam - PE Template

Document Normal Lumbar Spine Exam Findings

Document the Abnormal Lumbar Spine Exam Findings

Document a Multi System Orthopedic Exam

Document the Abnormal Thoracic Spine Exam Findings

Document Normal Findings for the Shoulder

Orthopedic Physical Exam Templates

Document Abnormal PE Findings in the General Exam - PE Template

Document Normal Lumbar Spine Exam Findings

Document the Abnormal Lumbar Spine Exam Findings

Document a Multi System Orthopedic Exam

Document the Abnormal Thoracic Spine Exam Findings

Document Normal Findings for the Shoulder