Description

A screen designed to document a patient's Physical Examination.


Configuration

There are multiple methods to configure or alter the existing settings of these options. It is crucial to understand that these configurations are specific to each user.

  • On the Clinical Evaluation screen: Right-click on any section to add, delete, or edit entries.


Access 

  • Through the Side Bar section: To access the Physical Exam button, click on it in the Side Bar of the Progress Note screen. If the Physical Exam button is missing, click on the Settings button on the toolbar of the Progress Note screen, then choose the Side Bar Settings option. Next, find the Physical Exam item in the available items area on the right side of the screen and drag it into the items window on the lower left corner of any Side Bar category. Finally, click the Save button to apply the changes. The Side Bar will update, and the Physical Exam button will now be visible under the category where you placed it.
  • Through the Search section: Click on the Search button located on the left side of the screen, then select the Physical Exam button.
  • Through the Clinical Evaluation section: Click on the Physical Exam text in the Clinical Evaluation section.  


Sections


Buttons

  • Physical Examination: The Physical Examination screen is displayed to record any injuries, trauma, and other physical conditions of the patient.
  • Procedures Templates: Enables the addition of procedure templates for the patient's clinical evaluation. 
  • Refresh: Press the refresh button to update the screen after loading options from the Template Store.
  • Leave Note Open: Allows the patient's evaluation to remain open.
  • Order Sets: Enables the management of Order Sets without departing from the patient's clinical evaluation.
  • Load Last: This function loads the items that were selected during the last evaluation for a particular patient.
  • Save as Template: Save the current evaluation as a template for use with other patients.
  • Select Template: Choose a previously saved evaluation template.
  • Save: The selected items are loaded into the clinical evaluation window of the current progress note.
  • Cancel: Exits the screen.
  • Show Previews Notes: When pressed, a column will be displayed that allows the user to preview the clinical evaluation before saving it.
  • Show Search Panel: When pressed, a column will be displayed that allows the user to preview the clinical evaluation before saving it.


    Sort by custom order: Selecting this option allows you to sort the options as they were registered.

    Sort alphabetically: Selecting this option allows you to organize in alphabetical order.

  • Filter By Patient: When selected, it allows you to filter the options by patient.
  • High risk of falling: Select this option, if the patient is a person prone to fall. (This field will be displayed as long as the office or facility is not identified as an emergency room).
  • Life expectancy is 6 months: Select this option, if the patient has an estimated time to live of 6 months. (This field will be displayed as long as the office or facility is not identified as an emergency room).
  • Include All Past History in progress note: By selecting this option, the checked options will also be displayed in the “Advanced Progress Note / Clinical Evaluation” screen in the section called “Past History”.
  • Apply Normal: Press to identify the selected options as normal.
  • Select Past History: Select the specific patient history you wish to include in the progress note.
  • Filter Templates By Type: By selecting, you can filter the “Templates” by categories.
  • Templates: Allows you to select a “Template” for patient evaluation.
    • Apply: Pressing it will display the selected “Template”.
    • Clear: Pressing will delete the selected “Template”.
    • Load Last: Pressing will display the last “Template”.
  • 4 Grids: The different options for patient evaluation will be displayed.


Edition Screen


Clinical Evaluation display on the progress note screen