[ Help Main ] > [ Main Menu ] > [ Patient Search ] > Patient Search Results ] > [ Patient Menu ] > [ Conducting a New Office Visit ] > Physical Exam

Tip:

  • You can quickly edit dropdown lists by using "Edit..." at the bottom of every dropdown list or auto complete list.
  • Growth Charts: You will only see growth chart options for patients under 36 months of age.

 

Vitals:

  • Please enter the patient's vital information accordingly.
  • When you enter temperature, weight and height, SynaMed automatically formats your input into the proper format. To convert to another unit of measurement, use the dropdown and select the unit. Below are some examples.
  You Entered AutoFormat Result
Temperature 98.6 98.6
Weight 58.9 59
Weigh 54.2 54
Height 3'2" 3'2
Height 34" 1'8

Note: The Body Surface Area (BSA) formula is derived from the Mosteller formula:BSA (m²) = ( [Height(cm) x Weight(kg) ]/ 3600 )½

Important: You can click on the green arrow to the left of the organ to expand and fill in detail information. Certain abnormal physical exam results are tagged with diagnosis ICD9 codes and will be used to suggest diagnosis and medications.

 

Functional Items Description
Copy From Previous Note Use this function to copy the information from the Physical Exam of the patient's previous patient note created by the same physician. You can then change symptoms that are different in this office visit from the last office visit if necessary. If there are already fields populated, those fields will not be overwritten by the copy.
Apply Default Settings This function populates all body part fields, including details of a body part with defaults you have specified for any patient. If there are already fields populated, those fields will not be overwritten by the copy.

You must be a physician to make a default list.

To make a default list:

  1. Go to any patient note.
  2. Select all the answers you want populated in all the fields and sub-fields.
  3. Click on Make Default.
Make This My Default Physical Exam  'Make This My Default Physical Exam' will take a snapshot of the all organ symptoms. This option is used in conjunction with Apply Default Settings and only appears if you are a physician. Please see the description for Apply Default Settings for instructions on how to use this function.

Note: Office visit information is saved every time you move onto a new tab or by clicking "Save and Go To Patient Menu". You may experience multiple listings of the same visit for a day. Select the session that you might have digressed from earlier and continue with that session. All other sessions for that day can be ignored or marked for deletion. Please exercise precaution when deleting office visit(s).

 

Customizing:

  1. This section can be customized at the user level by going to [ Custom Settings ] - [ Patient Notes ] -[ Physical Exam ] from the [ Main Menu ]. If you want to add another category, you must be a group administrator to do so in the Group Administrator's section from the [ Main Menu ] at the group level. After adding new categories, individual users will have to activate any new categories in [ Custom Settings ] - [ Patient Notes ] -[ Physical Exam ] from the [ Main Menu ].
  2. To quickly customize this section at the user level, click on "Customize Physical Exam" at the bottom of the section. This will being you to the screen located in [ Custom Settings ] - [ Patient Notes ] -[ Physical Exam ] from the [ Main Menu ].

 

You can create various P/E templates with different organ groups in each one. For example, you may have one template with "General Appearance", "Eyes", and "ENT". You could then create another P/E template with "General Appearance", "Cardiovascular", and "Respiratory".

The template remembers:

  • Bodyparts to include and their order
  • Whether or not a body part is expanded
  • The default values of each bodypart content

Customization

  • Values will be customized on the p/e section of cadnote where a user can rename, save, copy, delete settings.
  • Template structure, the bodyp arts to include, and the order of the organ systems can be customized directly in the physical exam or via "Customize", "Customize P/E", starting at the main navigation bar.

Default P/E

  • The default P/E is the template containing all the bodyparts to include and their order for when no specific P/E setting is applied.
  • You cannot rename nor delete this setting.
  • If you try to apply a P/E setting that has no bodyparts defined for it, the default P/E will load up.

Deleting P/E Setting

  • If you go to customize P/E from the office note and delete the P/E setting that is currently loaded on the physical exam, clicking on close and refresh note will cause the P/E section to reload on the default P/E setting.

Renaming P/E Setting

  • If you go to customize p/e from the cadnote and rename the p/e setting that is currently loaded on p/e, it will refresh the name of the p/e setting when you click the close and refresh note page.

FAQ:

Can I take off some fields from the vitals section?

Yes, this section can be customized in user profile.

How can patients sign registration forms?

They can sign the forms by using template/form drawings: scan in the document and you can draw/sign over it.

How do you store a patient-signed HIPAA form in the system as fast as possible?

Go to P/E drawings->create new form/drawing-> append picture, fill out all the forms, and click save.  Right now we are working on the patient portal so that the patient can view the HIPAA form at home, and sign it either electronically or digitally.  Then the office can append the file to the patient.

I have forms requesting for procedures sent in from hospitals, can I fill it out electronically, and then fax it back to the hospital?

The only way to do it right now is through P/E drawings.  Unless you get it in the incoming fax, print it, then rescan and fax it out.

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