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Document the Physical Exam (Detailed)

Version 14.19

Overview

This section will introduce users to the section of the Encounter note that is used to document the exam. To add or modify information in the form: 

  1. Click the Detail Exam button.
  2. Add an exam template using one of the below methods:
  • Click the dropdown 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 displays, click OK.
Note: If you need to include another exam, assessment or plan, follow the above steps to layer, or apply, additional templates.
  1. Change the Examination Point findings by clicking into the NL / ABNL column.
  2. To add additional examination questions do one of the following:
  • To view additional examination points, select the heading by clicking once.
  • To view additional exam groups, click the checkbox Show all groups.

  1. To add an examination point not included, select the Custom question drop-down arrow.
  1. Select the Exam Group.
  2. Type the exam question.
  3. Click the Add button to save the entry. 

You 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. The new note appears.
  3. In the new note, locate Detailed Exam. 
  4. Right-click and Paste Group into the new note. 
Version 14.10

Overview

This section will introduce the users to the section of the Encounter note used to document the exam. The user will be guided through the form to add or modify information. 

  1. Click the Detail Exam button.
  2. Select the template to apply by clicking the drop-down arrow at the top of the window.

Or

Begin typing the name of the template

  1. The Apply Template dialog box displays, click OK to apply the template sections.
  2. Change the Examination Point finding by clicking the NL / ABNL column.
  3. To add or edit additional examination questions do one of the following.
  • To view additional examination points, select the heading. 

To view additional exam groups, click to select the Show all groups checkbox.

To add an examination point not included, select the Custom question drop-down arrow.  Click the plus icon to save the entry.  

You 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. The new note appears.
  3. In the new note, locate Detailed Exam. 
  4. Right-click and Paste Group into the new note.