A physical examination is the process by which the patient’s body is investigated for signs of disease. It generally follows the taking of the medical history. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan.
Important points to keep in mind when recording the Physical Exam findings:
| • | Provider and Practice radio buttons: |
| o | If the provider’s favorite list is configured, the Provider and Practice radio buttons are displayed. By default, the provider’s favorite list is displayed to record the physical exam findings with Provider radio button preselected. Please note that the favorite list of the provider who is the primary provider of this patient is displayed, and not the logged-in provider. |
| o | If the provider’s favorite list is not configured, a list of all the findings configured for that practice is displayed with Practice radio button selected. |
| • | Quick List and Complete List: |
| o | If you want to quickly record physical exam findings, you can click the Quick List button from the top. This will list all the findings on a single page, where you can keep scrolling on the screen and record the findings very quickly. |
| o | The Complete List view will show all the body systems together on top. Clicking each body system will reveal the findings configured in it. You can record the findings and then click another body system link to record its findings. When all the findings of a specific system are recorded, that system will appear shaded in a gray color. “All the Findings” mean, there should be at least one option recorded for each Finding in that system. |
| o | Quick List and Complete List can be configured from the Physical Exam section in Administration. If Quick List is not configured, only Complete List is displayed. |
For details on configuration, refer to the Physical Exam under Administration.
To record a patient’s physical exam findings:
| 1. | In the charting elements ribbon, click Physical Exam. The Physical Exam screen is displayed. |
| 2. | Expand the General Notes section by clicking the icon. |
| 3. | Provide generalized notes related to patient’s findings in the text box provided. Click the macro icon  to add a new macro. The Macro Details screen opens. Do the following: |
| • | To insert the note from the pre-configured macro, select appropriate macro name from the drop down list and click Insert. |
| • | To add a new macro or edit the existing macro, click the Configuration button. Once added or updated the macro, click Save. |
Note: For more details on macros configuration, please refer to Configuring Macros.
| 4. | On the Physical Exam screen, do the following: |
| • | To view the provider’s favorite list of findings, select the Provider button. |
| • | To view a list of all the configured findings for the practice, select the Practice button. |
| • | To view a complete list of systems and findings, click the Complete List button. All the body systems are displayed together on top. |
| • | To view a quick list of systems and findings on a single screen, click the Quick List button. |
| • | Select check boxes for appropriate findings to record them in the system. |
| • | Once the abnormal values are recorded for findings, click All Others Normal. This will record the normal values for the remaining findings. |
| • | Click the General Notes button to reveal the empty box. Enter any notes pertaining to the Physical Exam in this box. |
| • | Click the anatomical drawing icon  to attach an anatomical drawing. Click the corresponding buttons to add a new image, attach an existing image, or import an image from the list of configured anatomical drawings. For details on Anatomical Drawing configuration, refer to the Anatomical Drawing section in Administration. |
Note: Once the drawings are attached, they will be displayed on the Encounter note on 2 different locations; the drawing uploaded for the Quick list will be displayed at the end of the section whereas the drawing uploaded for the Complete List will be displayed corresponding to the system to which it is added.
| • | Click the health check-up summary icon  to view the Summary. |
| • | Click the icon  to add new template to the system. |
Notes:
| • | To clear the recorded findings, click Clear All. This will clear out all the recorded findings for that system in Complete List. In Quick List, this will clear out all the recorded findings of that particular page. |
| • | To clear out the current findings, click the  icon. |
| • | Click the Finding title to enter a line item level note for each finding. You can also add a note by clicking the Notes link on the far right corner in the grid. |
| • | Once reviewed by the provider, select the Reviewed by check box. Your name will appear as a reviewer along with date and time. You can modify the date and time of your review. |
| • | Click the  icon to view the custom clinical forms created with questionnaire for the patient to record his/her health condition. Based on the selections done, the provider can review the patient's health condition for further treatment and the total points are also calculated automatically. The following are the forms created with questionnaire: |
| o | Oswestry Low Back Pain Scale |
| o | Disabilities of the Arm, Shoulder and Hand |
| o | Lower Extremity Functional Scale (LEFS) |
| o | Shoulder Pain and Disability Index (SPADI) |
| o | Global Rating of Change Scale (GROC) |
| o | Tinetti Balance & Gait Assessment |
| • | When all the findings of a specific system are recorded, that system will appear shaded in a gray color. “All the Findings” mean, there should be at least one option recorded for each Finding in that system. The gray color symbolizes that the entire section has been filled out completely. |
