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SOAPedia Home > Implementation Guides > 4. Customization > Discussion - Example of a Customized Docuplate > Objective Workflow Demo for URI > Create the Initial, Objective/exam for a URI Docuplate
Create the Initial, Objective/exam for a URI Docuplate
Table of contents
Table of Contents
This is a demonstration of one fashion to create the Objective or exam documentation for a custom URI docuplate. There are dozens of ways to approach this, but here, a SMARText item for a generic-general Objective-Normal exam, with a shortcut of ObjN is inserted as the starting point. Subsequently, unaddressed items will all be removed in one step. In general, it is easier to start with too much, and delete, rather than build from scratch.
Start with the ObjN SMARText Item
Here is the initial appearance after inserting ObjN into Objective.
Click the Exam Header
Clicking on Exam: brings up its pick list. Notice that, initially, all the items in the pick list have checks, so all of them are displayed.
Hide System Headers
Un-check pick list items in order to remove several of the systems from the curently displayed display.
So, we have removed (or hidden from display) the systems that we prefer to not have routinely displayed for this docuplate. At any time in the future, we can re-display the hidden systems by replacing the checks in the pick list.
Hide Specific Exam Elements
To remove (or hide) specific exam elements, the first step is often to first click on the System Header that contains the item to hide. For example, suppose the desire is to simplify or reduce the number of findings in the HEAD, EARS, NOSE AND THROAT. The first step would be to click on HEAD, EARS, NOSE AND THROAT: to display its pick list of exam elements.
Un-checking several exam elements in HEAD, EARS, NOSE AND THROAT: leaves the following displayed.
Similarly, the following exam findings were un-checked:
LYMPHATIC:
Neck node findings include Axillary node exam reveals no swollen or tender nodes under either arm.
Groin-Inguinal nodes demonstrate no adenopathy in the inguinal or femoral areas.
EYES:
Ophthalmoscopy
Pupils and Irises
NECK:
Thyroid exam reveals
LUNGS and RESPIRATORY:
Chest pelpation revelas Chest percussion demonstrates
HEART (Cardiovascular)
Heart palpation reveals
Edema-Varicosity Exam:
Pedal pulses demonstrate
Abdominal aorta exam reveals
Carotid artery findings include
Femoral arteries reveal
ABDOMEN (Gastrointestinal):
Liver/Spleen: No hepatomegaly or splenomegaly.
Hernia checking discovers no bulging or weakness in abdominal wall.
Anus and perineum inspection shows no lesions or masses.
Guaiac testing demonstrates[ no occult blood in stool from glove.
Skin Palpation:
Normal turgor and without induration or nodules.
This is how the Objective appears after hiding the exam elements, above.
The Remove Item Command
Using a different method to remove some of the specific exam findings, we will utilize a Remove Item command rather than un-check in a pick list. Right-Click on well-nourished, well-developed, and in no acute distress, and Click the Remove Item menu item.
Next, Click mild distress.
Right-Click External auditory canals and tympanic membranes are normal, and Click the Remove Item menu item.
Also, Remove:
nasal mucosa, septum and turbinates are unremarkable.
oral mucosa, salivary glands, tongue, tonsils, posterior pharynx, hard-soft palates are normal.
This has demonstrated one means to create the Objective data elements to include in a docuplate as in the URIcustomA example.
Path- Assessment Documentation
