Q: How do I Create a Normal Exam Docuplate

Originally Posted by apakula Hi wondering if anyone can help me. I am trying to make a smart text item for the physical exam sxn that works like the medications in that it will have a header for each organ system that i can click on and choose abnormal findings but the default will be normal. So instead of dose, form, refill etc in the medication it will say HEENT, LUNGS, etc and each can be clicked on. Any way to do this? Thanks

I think that what you are wanting to do is actually create a Docuplate with the normal findings set as the default, but still having the opportunity to modify those sections which have abnormal findings.

To do this, I would open a test patient, and in the OBJECTIVE section I would type "obj-", then use Ctl-Shift-> and select this from the list which pops up. This should insert the outline of the Physical Exam with blue headers for the different organ systems.

Next, go through and for each organ system, click on the header and then select the findings you want to indicate a "normal" exam.

Finally, hit F6 which will bring up the Docuplate Manager. At the top of the left side window will be an icon with a green plus sign. Choose this to add a Docuplate. The dialogue box will ask you for a shortcut for this docuplate, then to give the docuplate a name, and finally to add any searchable keywords. Fill these out, then hit Okay and your new Docuplate for a normal exam will be created. (You may want to make the shortcut name 'nlexam' so you will remember it.)

Now, when you are starting to see a patient, open their chart, start a new SOAPMF note, and then hit F5. Type in your normal exam shortcut and hit enter. The Objective field will now contain your Normal findings.

To modify these findings, click on the heading for the organ system which needs to be changed. From the Quick Access List, uncheck the normal finding (presumably you no longer want this) and click on any of the abnormal findings you want to record. DONE!     

Alan Drucker MD

drsane@sbcglobal.net

See:

Objective Documentation

Objective docuplate creation for URI in Tutorial - Create and use a customized docuplate