The physical exam can be written as free text or by loading previously recorded templates.

However, the software also contains a full standardized physical exam subdivided into medical systems based on Barbara Bates’ Guide to Physical Examination, Kaplan: United States Medical Licensing Examination (USMLE) Clinical Skills and other additional references. This will allow the user to easily set negative and positive findings in the physical in seconds by simply clicking a series of radiobuttons and checkboxes.

A pediatric physical exam is available as well and is automatically selected by the software upon detection of patient’s age.

 

The systems covered in the physical exam include:

  1. Vitals
    1. Vitals signs
    2. Parameters
  2. Constitutional
  3. Eyes
  4. Head & Neck
    1. Head
    2. Neck
  5. ENR
    1. Ear
    2. Nose & Throat
  6. Cardiovascular
  7. Respiratory
  8. Breast & axillae
  9. Gastrointestinal
    1. Abdomen
    2. Hernia
    3. DRE
  10. Genitourinary
    1. Urinary
    2. Penis
    3. Scrotal content
    4. External female genitalia
    5. Vagina
    6. Cervix / Uterus / Adnexa
  11. Neurologic Exam
    1. Mental Status
    2. Cranial Nerves
    3. Motor System
    4. Cerebellar Function
    5. Sensory System
    6. Deep tendon Reflex
    7. Special Signs
  12. Extremities
  13. Musculoskeletal
    1. TMJ joints
    2. Shoulders
    3. Elbows
    4. Writs and Hands
    5. Spine
    6. Hips
    7. Knees and lower legs
    8. Ankles and feet

 

Whenever needed, it is possible to attach files or pictures taken during the physical examination that will be stored in the patient’s records.

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