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Complete Physical Exam Form

By Chris Sedergreen -- For various reasons I haven't been happy with the earlier CPX form that came with OSCAR. No doubt we all have our idiosyncratic approaches to both the performance of a CPX and the recording of our observations. Moreover, what does "Complete" really mean? And how 'Complete' is our recording of our observations? When we simply look at a patient we are making numerous observations that we don't necessarily record, perhaps because to do so would be labour intensive. Also, the recording of 'negative' or 'normal' findings is often overlooked for similar reasons. Yet it is probably becoming increasingly important to do so, especially in an increasingly litigious world. Attached is a 4 page CPX eForm - the HTML and the PNGs. Also there is a sample CPX on my long-time patient and friend, Mr. Bilbo Baggins, as well as the Word document that I created to be the template. If anybody feels like it they can play with and edit this. I certainly don't think the resulting form is ideal and if anyone has ideas for further improvement please feel free. Here are some of the advantages: It prints very nicely in the event that a printed copy was ever needed. Values for height, weight, waist, BMI, and sitting BP are pushed to the database when entered into the form, so that they should show up in other forms such as Hypertension and Diabetes management forms. A large number of items are pre-checked as "Normal" as the default, which should save quite a bit of time recording. Sides are colour coded - Red for left and Green for right (port and starboard colours if you happen to be a mariner or aviator). This should make the form a little more easy to read and use. For the majority of ranges of motion the 'normal' is listed as an aide memoire. Certain clinical tests/signs - e.g. Lachman, Lhermitte, Trendelenburg are included as an aide memoire to remind the examiner to do them if applicable. Gender-specific body parts are colour coded for easy reading and recording. Lots of "Comment" areas in case there is a need to enlarge on findings. A 'Problem List" at the beginning of the form (draws from "Ongoing Concerns" in the database) An area to record a Diagnostic Summary and another to record the Treatment Plan. Editing the HTML wouldn't be a hugely difficult task if a user wanted to change some of the default settings, e.g. from N/E ('not examined') to Nor ('Normal') in the check-box areas. The disadvantages that I see are: To cram so much information into 4 pages I had to reduce the font to 11 points. Readability is improved however by using a bold font. The CPX is still by no means "Complete", although it is a lot more so than the previous version. It lacks line drawings and the ability to draw over them, that most of us have used with paper records. I expect this CPX form to continue to evolve over time - or even to be replaced by something better. Chris.

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