Physical Exam Templates

1. Display the Physical Exam Templates page: On the Main Menu, click Settings > Clinicals. In the left menu, under Practice Links — Exam, click Physical Exam Templates.
2. Template name — Enter a unique, descriptive name for the new PE template.
3. Sex — You can specify a patient gender, so that template checkboxes for male and female patients appear only for the appropriate patients.
4. Age range — You can specify a patient age range, so that pediatric and geriatric PE template checkboxes appear only for the appropriate patients.
5. Specialty — You can designate this template as appropriate for a particular specialty.
6. Ordering — Enter a digit to indicate the order in which the template is listed in the Physical Exam section. This number also determines how template content is organized when multiple templates are used simultaneously during an encounter. The template with the lowest ordering number serves as the basis for content organization.
7. Rollup — Select Y if you want this template to "hide" paragraphs by default. A hidden paragraph has a plus icon next to it, which can be used to display the paragraph. (A displayed paragraph has a minus icon next to it, which can be used to "hide" the paragraph.)
8. Note — Enter notes about this PE template.
9. Click Add. The new template appears in the list of templates at the bottom of the page.
10. To add elements and complete the content of the template, follow the instructions to add elements to a physical exam template.

Note: When you use the Sex and Age range fields in a template, make sure that the template is used in the encounter only for patients who meet the criteria that you used to create the template. For example, make sure that the patient falls within the age group specified by the template or is of the correct gender.

1. Display the Physical Exam Templates page: On the Main Menu, click Settings > Clinicals. In the left menu, under Practice Links — Exam, click Physical Exam Templates.
2. Click the update link for the template that you want to update. The template name appears, with a link to add paragraphs.

Add a paragraph, sentence, and findings to the template

3. Click the add paragraphs link. The selection window appears.
4. Click the linked name of the first paragraph that you want to add to your new template. The paragraph link expands to reveal the list of available sentences.
5. Click the linked sentence that you want to appear in your paragraph. A list of findings with checkboxes appears.
6. Select each finding that you want to appear in the sentence.
7. Click Choose. The selection window closes and the resulting paragraph appears on the Physical Exam Templates page.

Add more sentences and findings to the paragraph

8. To add sentences to the paragraph, click the add sentences link that appears at the top of the paragraph. The selection window appears.
9. Click the same paragraph name. The paragraph link expands to reveal the list of available sentences.
   Note: You can also select a different paragraph name if you want to add a sentence that is listed under a different paragraph.
10. Click another linked sentence that you want to appear in your paragraph. A list of findings with checkboxes appears.
11. Select each finding that you want to appear in the sentence.
12. Click Choose. The selection window closes and the resulting paragraph appears on the Physical Exam Templates page.

Add more findings to a sentence

13. To add more findings to a sentence, click the add finding link that appears at the bottom of the list of findings for the sentence in the paragraph. The selection window appears.
14. Click the same paragraph name. The paragraph link expands to reveal the list of available sentences.
    Note: You can also select a different paragraph name if you want to add a finding from a sentence that is listed under a different paragraph.
15. Click the sentence to which you want to add findings. A list of findings with checkboxes appears.
16. Select any additional findings that you want to appear in the sentence.
17. Click the Choose button. The selection window closes and the resulting paragraph appears on the Physical Exam Templates page.

Edit or remove individual findings

18. To remove a finding from a sentence, on the Physical Exam Templates page, click the x icon next to the edit link to the right of the finding.
19. To edit the finding type, on the Physical Exam Templates page, click the edit link to the right of the finding.
    Edit fields for the finding appear.
20. Use the menu to select the desired finding type.
    Note: Changing the finding type does not reclassify that finding in the global findings database. The change applies only to the current physical exam template.
21. Click Close.

Complete the template updates

23. Repeat the process to add paragraphs, sentences, and findings.
24. Click Update to save your changes.

Sentences and findings for the physical therapy specialty

 

History of Present Illness and Physical Exam templates used for the physical therapy specialty include sentences and findings that you can use as patient goals in the Assessment / Plan section and that you can track over time in physical therapy episodes.

• (G) appears next to sentences and findings that you can use in the Assessment / Plan Patient Goals section.
• (T) appears next to sentences that you can track in the physical therapy episode Progress section.

1. Display the Physical Exam Templates page: On the Main Menu, click Settings > Clinicals. In the left menu, under Practice Links — Exam, click Physical Exam Templates.
2. Click the update link for the template that you want to update. The template details appear in the fields at the top of the page, and findings appear below.
3. Edit the template fields as needed.

To edit findings or add an underscore to a finding

4. Click the edit link to the right of the finding. Additional editable fields appear.
5. To create an underscore, in the Name text box, enter a space, then enter two underscore characters (an underscore is an uppercase dash) followed by another space (for example, "Range of Motion __ Degrees") where you want to be able to enter data values.
   
   

   Important
   You can include only one free-text field using underscores per finding.

6. Edit other fields as desired, and then click the Close button for the findings fields.
7. Scroll down to the bottom of the list of findings and click the Update button to save all changes.

1. Display the Physical Exam Templates page: On the Main Menu, click Settings > Clinicals. In the left menu, under Practice Links — Exam, click Physical Exam Templates.

2. Click the save as link for the template that you want to copy. The template details appear at the top of the page.
3. Template name — Enter a new, unique name for the new template. No two templates can have the same name.
4. Click the Save As button at the bottom of the page to save the new template. The new template is now listed with update, delete, preview, and save as links.
   Note: A duplicate warning appears if the template name is a duplicate.
5. Click the update link for the template that you created. The template details appear at the top of the page.
6. Edit the template details as desired.
7. Click the Update button to save your changes to the template.

1. Display the Physical Exam Templates page: On the Main Menu, click Settings > Clinicals. In the left menu, under Practice Links — Exam, click Physical Exam Templates.

2. In the list of global templates at the bottom of the page, click preview for the template to view. A preview of the template appears under the input fields at the top of the page.
   Tip: To locate the template that you want to copy, click a column header to sort the list by that column.
   Note: A global template with the same name as an active local template cannot be copied. You must first change the name of the local template before you can copy the global template.
3. Scroll down to the bottom of the template preview and click Copy to make a copy of the global template for use in your practice.
4. A message appears at the top of the page confirming that the template has been copied.
   If the messages says "This template has NOT been copied," review and resolve the conflicts, or click the link to accept these contradictions.
5. Template name — Enter a new, descriptive name for the new template.
6. Edit the remaining fields as needed.
7. Click Add. The new template appears in the list of your practice templates (in the middle of the page).

1. Display the Physical Exam Templates page: On the Main Menu, click Settings > Clinicals. In the left menu, under Practice Links — Exam, click Physical Exam Templates.
2. Click the delete link to the left of the physical exam template that you want to delete. A warning message appears.
3. Click OK to delete the template, or click Cancel to keep it. The physical exam template appears disabled in the list, with an undelete link that you can use to restore the physical exam template.
   The audit history of the physical exam template is preserved.

Templates are constructed as a series of "paragraphs," which contain "sentences" and "findings."

• Paragraphs are the highest level of organization, usually a body system or area.
• Sentences are the second level of organization.
• Findings represent a unique clinical concept and are attached to a unique identifier that is used to run reports and generate an Evaluation and Management (E&M) code using the E&M coder.

The global template data available in athenaOne is from a system of standardized medical terminology called MEDCIN. Each finding contains a unique underlying MEDCIN ID that is used by the system to determine the finding to update. The MEDCIN ID does not change, even if the finding is renamed.

In the sample below, the paragraph called Constitutional has a sentence called General Appearance, which has five findings: well-nourished, in no acute distress, obese, cachectic, ill-appearing.

If a finding is renamed (if obese is renamed as overweight), it will still share the same MEDCIN ID as the original finding. Therefore, if both findings exist within the same encounter, selecting or updating one finding will automatically select or update the other finding.

Important: Updates to finding names must preserve the meaning of the original finding name to ensure consistency across templates.

You can drag and drop the elements in a template to rearrange the content.

Tip: Use the Expand/Collapse all paragraphs option for easier editing.

1. Left-click any paragraph, sentence, or finding heading.
2. Hold down the cursor while dragging the entire section to the new location.
3. Release the cursor button.
4. To save the new arrangement, click Update.

Tip: Look for the Preview Box (dotted-line outline of a box) before you drop the section into place.

Using underscores in findings allows you to enter data values directly into the finding when you use the template during an encounter. For example, you can add specific data into a finding such as "Range of Motion __ Degrees" or "weight gain (__ lbs)" by clicking into the underscored blank space. The data value entered into that finding appears in the Encounter Summary, for example, as "Range of Motion 90 Degrees" or "weight gain (5 lbs)."

These free-text fields work with athenahealth-created and MEDCIN-based findings. To add a free-text field using underscores to an existing finding, you can edit the finding to add an underscore within it.

Important
You can include only one free-text field using underscores per finding.

With the jotter tool, you can open a blank jotter and create free-hand images to help document the patient's condition. Each blank or anatomical drawing canvas displays the jotter toolbar, which includes basic annotation tools.

Note: To enlarge the jotter area, click the down arrow at the lower right corner of the jotter.

From the following encounter sections, you can select one or more images to annotate:

• History of Present Illness — Templated
• Review of Systems
• Physical Exam
• Procedure Documentation

Any images that you select are included as part of the legal encounter record and appear on the Encounter Summary.

Use the Anatomical Drawings page to add images for use with the jotter.