Exams

Exams Overview

The Exam chart tab is used to document any patient exams, injections, procedures, labs, imaging, etc. that may have been completed during an office visit. It is an encounter-based chart tab where data differs from encounter to encounter if the data does happen to be the same or similar there is an option to copy forward from the previous encounter. More about this here: https://officeemr.knowledgeowl.com/help/notes-clinical-marker

Exams can be configured by specialty and will allow for individual physicians to document in the most efficient way for them by offering options for freehand typing, dictation, and templated data you can click through. 

Once the exams are configured for your specialty, they can then be customized at the user level by utilizing our User Default feature described here: https://officeemr.knowledgeowl.com/help/user-template-defaults

1. Open the patient's chart, select the Exams chart tab.
   
    
   
   
2.  The Exams screen will load- select the Physical Exam template you will be documenting (varies per practice).
   
   
   
   
3.   Then you can either click all of the necessary boxes for this patient OR you can click the Defaults button. This will load the details saved as a default and then you can edit as needed.
   
   
    
4. Document the patient's Exam as appropriate.
   
   
5. Once you have it completed, click Save.
   
   

1. Once in a patient's chart, select the Exams chart tab.
   
   
   
   
2.  Click on the History button from the menu bar at the top of the screen.
   
   
    
3.  Click once on the Exam entry that you want to copy forward.
   
   
   
   
4. Select Copy from the menu bar.
   
   
   
5. The previous encounter Exam will load, make the necessary changes.
   
   
   
   
6. Press Save when you are done adding all changes.
   
   

Users can setup and use template default values for Exams using the following steps: 

1. From the EMR Portal- Open a test patient chart using the Patient Search.
   
   
   
2. Click on the Exam Chart Tab 
   
   
   
3. Select the Template to set default values for
   
   
   
   
4. Select the ...More menu and then Default Setup option.
   
   
   
5. Press the New button.
   
   
   
6. Enter a Name for the set of defaults (Check the Only for Me checkbox to keep the defaults private to your user id.)
   
   
7. Go through the template and set the default field values.
   
   
8. Press the Save button