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Recording Objective EHR Information

  1. recording objective ehr informationIn the EHR window, click a patient in the EHR status window and click “View Exam”
  2. Click the Objective tab.
  3. On the subluxation diagram, click on the right or left side of the vertebrae to denote the specific spinal restrictions or subluxations
  4. Click the center of the spine to denote bilateral restrictions. (NOTE: Hold the left mouse button or your finger down and drag across each area on the spine)
  5. To change the adjustment technique, click the drop-down list labeled “Adjustment Technique” which is located above each spinal region on the subluxation diagram. (NOTE: you will see the technique name change between the spinal regions)
  6. To load prior visits findings, click the button at the top labeled “Load Prior”.
  7. Record extremity joint restrictions by clicking on the area located in the appropriate joints on the extremity diagrams
  8. Record muscle tension or spasm by clicking an area on the hypertonicity diagram and select the appropriate muscle listed in the pop-up window. Switch front or back by clicking the smaller image in the upper right corner. (NOTE: The selected muscles will not appear in this view but will be listed in the printed notes, and an outlined area will be shown on the diagram)
  9. Record an area of tenderness by clicking area(s) on the tenderness diagram. Switch front or back by clicking the smaller image in the upper right corner. (NOTE: The selected areas will not appear in this view but will be listed in the printed notes, and an outlined area be shown on the muscle diagram)
  10. Record custom tests or findings by clicking the less than sign “< “in the upper left corner of the box under the words “Tests Performed”, and check the box next to the test in the slide-out window. (NOTE: multiple tests can be selected in this box).
  11. Record a functional disability by clicking the drop-down menu beneath “functional disabilities” and select a disability from the custom list. (NOTE: To add multiple disabilities, click the button “More” next to the drop menu and select from drop menus)
  12. Record a custom disability by typing the activity that results in symptoms. The phrase “causes symptoms” will appear 2 seconds later.  (NOTE: A recorded functional disability will automatically add the opposite statement as a “functional goal” in the plan tab of your notes. This can be viewed by clicking the plan tab of the EHR application.)
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