Physical Exam

Clinical content should be customized at the CLINIC level and copied to all users at the clinic to ensure consistent documentation in the patient record

The Structured multi-system Physical Exam is comprised of 10 body areas and 12 organ systems:

General Appearance (Constitutional) ● Head ● Eyes ● Ears, Nose, Mouth, Throat ● Neck ● Respiratory ● Cardiovascular ● Chest ● Abdomen ● Lymphatic ● Skin ● Musculoskeletal ● Back ● Right Upper Extremity ● Left Upper Extremity ● Right Lower Extremity ● Left Lower Extremity ● Gastrointestinal ● Genitourinary ● Genitalia ● Neurological ● Psychiatric

Each area and system contains a list of elements that can be selected to document the exam findings.

Genitourinary and Genitalia display different elements based on the patient’s Birth Sex

The Structured multi-system Physical Exam is comprised of 2 body areas and 12 organ systems:

Constitutional ● Eyes ● ENT and Mouth ● Neck ● Respiratory ● Cardiovascular ● Chest (Breasts) ● Gastrointestinal ● Genitourinary ● Lymphatic ● Musculoskeletal ● Skin ● Neurologic ● Psychiatric

Additionally, there are 10 single organ system exams available for use:

Genitourinary ● Musculoskeletal ● Respiratory ● Hem/Lymph/Immun ● Neurological ● Cardiovascular ● ENT ● Skin ● Eye ● Psychiatric

Each area and system contains a list of elements that can be selected to document the exam findings.

Genitourinary displays different elements based on the patient’s Birth Sex

Depending on the customization of the clinical content, some items may require additional input or description details when selected

1. Go to Encounter > Physical Exam > Structured
2. Optional for 1997 E/M Coding Guidelines exam: select the exam type from the selection list
3. Click a body area or organ system relevant to the visit and select all the elements that correspond to the exam findings
4. Repeat for each area or system examined

The dynamic display field will display the structured Physical Exam as it is being documented.

Using the ‘Apply Normal’ Button

Clicking Apply Normal and selecting one or more body area or organ systems will select all elements that are designated as Normal findings for those areas. Clicking Apply Normal and selecting Select All will select Normal findings for all body areas and organ systems.

Click Apply to add these selections to the physical exam documentation.

The designation of a ‘Normal’ finding is assigned to elements in the physical exam when customizing the PE clinical content.

The Last button can be used to populate the current PE with information documented during any of the patient’s previous encounters.

1. Go to Encounter > Physical Exam > Structured
2. Click Last
3. Select the encounter with the PE to be used
   1. Only encounters that are the same Encounter Type as the current visit will display for selection

   2. Optional: click Get Previous 5 Physical Exams to view more/older encounters

4. After reviewing the previously documented PE, click the Select All checkbox to apply all information to the current PE or select the checkbox for the individual areas or systems to apply only that information to the current PE
   1. Narrative text from the Notes tab can be included by selecting the Notes (Additional Info) checkbox
5. Click Apply

1. Go to Encounter > Physical Exam > Images
2. Click Import

3. Locate and select the file from the local computer and click Open

   

4. Optional: Repeat the process to attach more files

1. Go to Encounter > Physical Exam > Images
2. Click
3. Click Capture

1. Go to Encounter > Physical Exam > Images
2. Click Draw
3. Select a Background image for the drawing or click and click Capture to take a photo
4. Optional: type a Description for the drawing
5. Use the drawing tools to complete the drawing:
   • Pencil: click , select a line width, and select a color from the palette to draw with the pencil tool
   • Shape: click , select a shape, and select a color from the palette to add shapes to the image
     • Use the slider to make the shape larger or smaller
   • Text: click , select a font size, select a font style, and select a color from the palette to add text to the image
   • Eraser: click and select a line width to erase any pencil lines or shapes on the image
6. Click OK