Physical Exam

Estimated reading: 10 minutes

Learn how to setup physical exam templates, observations and create pet health report cards for patients, using the Physical Exam feature.

Before you start

Security

Setup

Important!

  • If you need to change the Normal/Abnormal/Did Not Examine status on the physical exam, or change the default template, do this first to avoid overwriting any changes you have made to observations or vital signs.

Set up Physical Exam

The Physical Exam feature is included with all Cornerstone systems. It allows practices to record physical exam observations and comments using standard body system templates and print a Pet Health Report Card.

Defaults

The Patient Exam defaults allow you to specify preferences for printing Pet Health Report Cards.

Navigate to Controls > Defaults > Practice and Workstation > Physical Exam.

  • Print when saving/posting exam: Check to have the report card print automatically when saved or posted. Specify the number of copies to print.
  • Print patient picture: When checked, indicates you want the patient’s picture to print on the report card.
  • Print abnormals in red: If you have a color printer, abnormal observations headings will print in red, when the box is checked.
  • Footer message: Select a message to print in the footer of the Pet Health Report Card. Messages can be set up or edited in Billing messages.

Click Apply to save your changes and continue setting defaults or click OK to save your changes and close the window.

System template setup

Physical exam system templates include the body systems that apply to the type of physical exam being performed.

System templates can be set up for specific species. More than one system template can be set up for each species.

Only one system template can be designated as the default. The default system template automatically displays when the physical exam is started for a patient. A different template can be selected if needed.

Navigate to Lists > Physical Exam > System templates.

  1. Type a name for the template in the Description field.
  2. If this template should be used for the majority of your physical exams, click Default.
    • Only one template can be selected as default.
    • If another template is marked as the default, clicking the Default check box here will deselect the other template.
  3. Click the gray box to the left of the system, to include a body system on a template. A check mark will display.
    • Click the check mark to remove the body system from the exam template.
  4. Select a default observation status for the body system, from the drop down list.
    • Options include: Normal, Abnormal, Did Not Examine
    • The observation can be changed at the time of use.
  5. Arrange the systems in the order you want them to display on the physical exam on the Pet Health
    Report Card.
    • To move a system, click the system you want to move.
    • Click the Up or Down arrow to move the system up or down in the sequence.
  6. Click OK to save the system template.
  7. Click Close.

In the Physical Exam Setup window, additional body systems can be set up, if needed.

Observation text for each body system can be set up in advance for abnormal, normal and did not examine statuses. More than one set of observation text can be set up for each body system status. Only one set per body system status can be designated as the default observation. Some standard body system observations are included with Cornerstone software.

Add a system

Navigate to Lists > Physical Exam > Physical Exam Setup.

  1. Click an existing system and click Update or click New.
  2. Type the system description in the Description field.
  3. If you want the Vital Signs/Weight icon to display with this system in the exam Observations tab, select the Vital Sign System check box.

    Note: See Including Vital Signs Information in Physical Exam for information on including vital sign information in an exam at the time of use.
  4. Click OK. The system will be inserted alphabetically.

To delete a body system, select the system and click Delete. Note: A system can only be deleted if no information has been linked to the system and it has never been used on a patient.

To add or edit an observation

  1. On the Physical Exam Setup window, click within the left pane and then click the plus sign [+] to the left of the body system. Folder options will expand.
  2. Click the plus sign [+] to the left of Observations.
  3. Select the observation status of Normal, Abnormal or Did Not Examine.
  4. Click an existing system and click Update or click New.
    • In the Observation text field, type the new observation message.
    • To edit an existing observation, position the cursor in the applicable spot in the observation and make changes.
  5. If the observation text applies only to a specific species, select the species to which the observation text applies.
  6. Click Default, if this should be the default observation text for this observation type (Normal, Abnormal, Did Not Examine). Only one set of observation text can be selected as the default.
  7. Click OK to save the observation.
  8. When finished, click Close to close the Physical Exam Setup window.

Use the Physical Exam

Patient exam list

Navigate to either:

  • Toolbar > Physical Exam
  • Patient Clipboard > Right click patient > Physical Exam
  1. Do one of the following:
    • Click New to start a new exam.
    • If you want to modify information on an open exam, click the exam that you want to modify and click Select.
    • If this is an open or closed exam for which you want to enter recheck information, click Recheck.
      Note: The recheck option creates a copy of the original exam record to which you can add your observations. This exam record is labeled as a recheck exam. Both the original and recheck exam are saved in patient history.
  2. Record the physical and exam.

Add a physical exam to a patient record and print a pet health report card

Naviage to either:

  • Toolbar > Physical Exam
  • Patient Clipboard > Right click patient > Physical Exam
  1. Click New to start a new exam.
  2. Click the Vital Signs/Weight to update the patient’s weight and other vital signs, if needed.
  3. Verify the Admit date is correct and change, if needed.
  4. Select Staff and Tech, from the drop down boxes.
  5. The default physical exam template will be displayed. Select a different template, if needed.
    • Standard observations are included on the template, but the observation status (Normal, Abnormal or Did not Examine) and text can be changed to reflect the results of the patient’s exam.
  6. To add or remove a body system in the physical exam, right-click anywhere on the physical exam and from the pop-up box, click Systems.
    • A list of body systems displays. Click the check box to the left of the body system to add or remove.
    • Click Finish to close the window.
  7. To record exam observations and comments:
    • If this is a normal exam with no changes to observations, click Save or Post. Posted exams cannot be changed.
    • To edit the observation text on the Physical Exam window, position cursor where you want to edit text and make changes.
    • If a body system was set up as a “vital signs system”, a Vital Signs/Weight icon will display next to those systems on the exam Observations tab.
      • Click the icon and enter and/or select vital signs to be included as text lines within the observation text.
      • The vital signs entered during the exam will print on the Pet Health Report Card.
    • To change the status of an observation, right-click the observation and select the applicable status: Normal, Abnormal or Did not Examine.
    • To select a different set of pre-defined observation text, click the Magnifying Glass icon to the right of the text you want to replace. A pop-up list displays.
      • From the list, select the observation text to use and click Select.
    • To add multiple lines of alternative observation text: Anywhere on the physical exam, double-click or right-click and select Update.
      • Select the applicable system and status and click Search.
      • Under Observation text, from the list of observation text lines, click an applicable observation text line and click Add.
        • Repeat until all applicable text has been added.
        • When finished, click OK. Click Finish to return to the physical exam.
  8. Click Note to type any comments. Click OK. The exam note can be modified on an open or new exam.
  9. When finished, click Save or Post. A dialog box showing the displays. Make changes to the defaults, if needed.
  10. Click Save or Post. The option available will depend on your choice in the Physical Exam window.
  11. If Print was selected, the Pet Health Report Card prints.

Update an open exam

When an open exam is selected, the Physical Exam dialog box contains the previous exam’s information. You can modify or add to this exam with the necessary treatments or instructions.

Navigate to either:

  • Toolbar > Physical Exam
  • Patient Clipboard > Right click patient > Physical Exam
  1. Select an open exam from the Patient Exam Lists.
  2. Make changes as needed.
  3. Click Save to leave the exam open or Post to close the exam.
    • Change settings, as needed.
  4. Click Save or Post. The option available will depend on your choice in the Physical Exam window.
    • If Print was selected, the Pet Health Report Card prints.

Performing a recheck

You can perform a recheck exam on a closed or open exam. When you choose recheck, the Physical Exam dialog box contains the previous exam’s observation information only. You can add to this exam with necessary follow-up care instructions and treatments. An example of a recheck would be a broken limb, when you need the patient to come in for additional x-rays.

Navigate to either:

  • Toolbar > Physical Exam
  • Patient Clipboard > Right click patient > Physical Exam
  1. Select an open or closed exam and click Recheck.
  2. Make changes as needed.
  3. Click Save to leave the exam open or Post to close the exam.
    • Change settings, as needed.
  4. Click Save or Post. The option available will depend on your choice in the Physical Exam window.
  5. If Print was selected, the Pet Health Report Card prints.

The exam displays with “Recheck”, next to the status on the Patient Exam List.

Additional information

Physical Exam

Related reports

  • Observations Report
  • Instruction Templates Report
  • System Template Setup Report
  • Open Physical Exam Report
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