Once you have added physical exams to a document skeleton, they can be edited to best suit the needs of the provider or providers who will be using them. Changes made to the exams in the document skeleton (e.g., changing Normal to Abnormal) are "document skeleton specific" and do not affect the items in the dictionary.
Order of list: The order of the list is the order the exams will be in when presented to the provider during the encounter. The default order of the exams in the list is based on the display order assigned to the items in the Organ Systems dictionary. You can change the order of the list in the document skeleton by left-clicking on an exam and dragging it to a different spot in the list. You can restore the original order of the exams by clicking the Reset Order button.
Remove any physical exams from the list by selecting the checkboxes and clicking the Remove button. You can also remove an individual exam by right-clicking on it and deleting it.
Side: To make an exam side-specific, RIGHT-click on the side you wish to choose. To automatically create an associated exam to address the opposite side, LEFT-click on a side.
Values: Values for exams will generally be set to Normal at the dictionary level, so normal values should be preselected in an exam by default. There may be cases when your providers wish to preselect abnormal values (e.g., associating certain abnormal values in an exam with a diagnosis code that is assigned to this document skeleton). In that case, left-click on abnormal values to select them (be sure to deselect any normal values that no longer apply). You can deselect any particular values by left-clicking. To return all values of an exam to normal, click on the Make Normal button within the exam or select several exams and click on the Make Selected Normal button.
Additional Notes: Clicking on the pencil icon in the Additional Notes column will open a free text box. This allows you to enter any notes that may be pertinent to this exam. These notes will become part of the exam documentation in the patient encounter if this document skeleton is selected.