Add Examination Details

Add examination information to a consult.

About this task

Procedure

To record examination details:
  1. From the PatientPatient Search or Patient Queue iconPatient Queue, select a patient and click Consult buttonConsult.
  2. In the Consult panel, in the Consult Notes section, click Hx/Ex.

    The History and Examinations modules are linked. When you click Hx/Ex, History is displayed by default.

  3. In the History & Examinations panel, on the History | Examinations toggle button, click Examinations to switch to the Examinations module.
    Along the top of each module are tabs for accessing different input sets. This example shows the General tab.
    Example Examination - General tab
  4. In the relevant category, record the required examination information. For more information, see Examination Categories.
  5. If you want to indicate No Abnormality Detected for each field of the selected category, click NAD category: in our example, NAD General.
  6. If you want to record No Abnormality Detected for an entire category, click NAD in a section or NAD category to record no abnormalities.
  7. If you change want to clear a category of all information, click Reset category.
  8. Click Add to Notes.

Results

The examination information from the current tab and all other updated tabs is added to the patient's consult notes. For example:
Example examination information in the consult notes.

What to do next

When a consult is exited, the examination information is displayed in the patient’s timeline.