Physical Exam

The Physical Exam encounter section is an optional section that can be applied to the encounter outline. This can be used to help document a Physical Exam regarding the visit within an encounter.

NOTE: If performing a Visual Exam (for example in a Telehealth/virtual event), you can toggle this Physical Exam encounter section to be a Visual Exam section instead. See more information in the Visual Exam guide.

Add a Physical Exam - Flowsheet

The Physical Exam encounter section points to a specific flowsheet configured in the system. This flowsheet can be customized for your needs. A configured flowsheet named Physical Exam in the flowsheet editor will display the data capture fields in the encounter Physical Exam section. Using the Physical Exam flowsheet allows your system to capture unique or custom information for your practice to document in an encounter within the Physical Exam encounter section.

To utilize a flowsheet method in , a flowsheet named Physical Exam must exist with contents.

NOTE: Physical Exam fields (when in expanded mode) reflect any chief complaint protocol(s) selected. Otherwise, if no chief complaint protocol is designated on the encounter, the Physical Exam section will default to offering our standard work related Physical Exam flowsheet questions. For more information on chief complaint protocols, please see separate guide Encounter Protocols.

Copy from Previous Exam

Within the Physical Exam encounter section, there is an icon that offers Copy from Previous Exam functionality.

The Copy from Previous Exam icon pops up a window to allow you to select Physical Exam field data that you wish to copy from the chart’s prior encounter(s) to this current encounter.

For more detailed information, please refer to guide Copy from Previous Exam.

Macros

If utilizing a Physical Exam flowsheet, library macros offered in the Physical Exam encounter section are a way to quickly insert predefined text with minimal user input depending on what library your encounter is set to or the Physical Exam section library that is set to.

For additional information on configuring and utilizing macros that can be utilized within the Physical Exam encounter section, please see separate guide Macros and/or Libraries.

Delete / Edit / View Physical Exam Captured Data

You can edit, delete, add to, or view the specific documented Physical Exam data from the encounter section.

Hover Options

Once Physical Exam data has been documented, one can edit, add to, or delete data for the specific Physical Exam data that was captured. If you do not have security permission to edit or add to observations, then you will not be able to.

From the section’s collapsed summary view, simply click on the values/data of the specific Physical Exam line item to edit on or add to. The data will be displayed in a border box where you can begin modifying or typing in more information.

Also while the encounter section is in summary collapsed view, icon options next to the stored data will display.

Trash Can icon: will immediately delete the stored data for the physical exam line item. Physical exam data stores as observations. If you do not have security permission to delete observations, the trashcan icon will still display, but upon click, the system will not allow the data to be deleted.

Eyeball icon: will pop-up the View Observation window to view more specific details of the specific physical exam data. Revisions, trending, and entry information will be seen. Physical Exam data stores as observations.

Expanded Encounter Section

Physical Exam data can also be edited on, added to, or cleared/deleted from the expanded encounter summary section. Once Physical Exam data has been documented, the encounter section can be expanded open by clicking anywhere on the grey title section bar. Then, the data can be clicked to edit & add to, or can click X to clear the data out of the field. If you do not have security permission to edit or delete observations, the system will not allow you to modify.

Encounter Stored Document

The Physical Exam encounter section does become part of the encounter visit note document once closed and archived.