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Document the Physical Exam

Version 20.7

Overview

The sections below instruct on how to enter physical exam information. The Detailed Exam is entered during either an Encounter or a Well Visit, and the Narrative Exam is entered only during an Encounter.

Document a Detailed Exam (Encounter or Well Visit)

  1. From within an open Visit Note, click Detail Exam in the Window Navigation panel.
  2. Add an exam template using one of the following methods:
  • Click the drop-down arrow in the All templates: field and select from the list.
  • Click into the All templates: field, enter the name of the template, and select from the list.
  1. Click OK in the Apply Template Dialog box.
  2. Change the Examination Point findings by clicking in the NL / ABNL column for each point.
  3. To add additional examination questions do one of the following:
  • To view additional examination points, click the group heading.
  • To view additional exam groups, click the checkbox Show all groups.

  1. To add an Examination Point that is not included, complete the following steps: 
  1. Click the Custom question drop-down, and select the Exam Group.
  2. Type the question in the blank field.
  3. Click the Add button to save the entry.

NoteYou can also copy and paste the findings of an entire system group into a new note. This is especially useful when you’d like your documentation to be the same in both notes, such as a Well Visit, and an Encounter or when you’re seeing siblings with the same conditions, where the findings are duplicated. To do this:

  1. Right-click on the System Group.
  2. Select Copy Group.
  3. In the new note, navigate to the Detailed Exam. 
  4. Right-click and Paste Group into the new note.

Document a Narrative Exam (Encounter Only)

  1. From within the open Encounter Note, click Narr Exam in the Window Navigation panel.
  2. Add an exam template using one of the below methods:
  • Click the drop-down arrow in the All templates: field and select from the list.
  • Click into the All templates: field. Begin type the name of the template and select from the list.
  1. The Apply Template Dialog box is displayed. Click the narrative radio button for the Objective (exam). 

  1. Click the OK button, the Narrative Exam window is displayed.
  2. To change or add findings in a narrative field, use one of the following methods:
  • Click into the text field and type additional exam findings.
  • Click into the text field, select the Phrase Construction button and insert phrases. 
  • Click the Def button to insert the default phrase.