Best Practice Guidelines: Healthcare Practice Management

7. Clinical information

7.2. General Examination Forms

The general examination forms are used to record observations made during a patient examination. Here we’ll discuss two types of general examination forms:

  1. General Examination
  2. Quick Note


General Examination

This form is structured in such a way to help practitioners quickly and easily capture their observations. The values entered into this form will also become part of the patient’s clinical history which can be reviewed to see whether a patient’s health has improved/declined over a period of time. When abnormal measurements are entered it will be indicated in red on the form. This form includes the following sections:


Physical Examination

This section is used to capture the following details:

  1. Complaint
  2. Notes
  3. Images
  4. Symptoms
  5. Vital measurements (e.g. blood pressure, pulse rate, temperature, BMI, waist/hip ratio, FRAMINGHAM score, etc.)
  6. Sideroom investigations (e.g. urine test, glucose, cholesterol, HIV, malaria, HDL)
  7. JACCOLD (Jaundice, Anaemia, Clubbing and Spooning, Cyanosis, Oedema, Lymphadenopathy and Dehydration)


Review of Systems

In this section you will find system visualisations, space to make notes about each sub-system and in some subsections you will find quick capture features like yes/no questions that allow the practitioner to easily capture their findings. The practitioner can also make annotations on the system visualisations. The information in this section can assist the practitioner with planning the treatment of the patient. This section is split into the following sections (subsections under each section will be indicated by the information between the brackets):

ENT and Ophthalmology

Eyes, ears, nose, mouth, throat, facial views and general notes.

This section can be used to review the ear, nose, throat, head and neck systems.

Respiratory

Signs of distress, chest wall, patterns of breathing, palpation, percussion, auscultation.

The human respiratory system is a series of organs responsible for taking in oxygen and expelling carbon dioxide. The primary organs of the respiratory system are the lungs, which carry out this exchange of gases as we breathe.

Cardiovascular

Heart rate, heart sounds/murmurs, precordial palpation, JVP/neck veins, ECG and general notes.

The cardiovascular system comprises of the heart and blood vessels and carries nutrients and oxygen to the tissues of the body.

Abdominal

Inspection, palpation, percussion, auscultation and general notes.

The abdomen includes a host of organs including the stomach, small intestine, colon, rectum, liver, spleen, pancreas, kidneys, appendix, gallbladder and bladder.

Musculoskeletal

Head, gait, arms, legs, spine and general notes.

A combination of the muscular and skeletal systems working together which includes the bones, muscles, tendons and ligaments of the body.

Genito-urinary

Breasts, cervix, inspection, palpation, percussion and general notes.

Genito-urinary system, or urogenital system is the organ system of the reproductive organs and the urinary system. 

Lymphatic

Inspection and general notes.

The lymphatic system is part of the vascular system and is an important part of the immune system, comprising a large network of lymphatic vessels that carry a clear fluid called lymph directionally towards the heart.

Immunological/Endocrinology

General notes.

The immune system is the body's defense against infectious organisms and other invaders and endocrinology is the collection of glands that produce hormones that regulate metabolism, growth and development, tissue function, sexual function, reproduction, sleep, and mood, among other things.

Dermatological

General notes.

Comprises the skin and its appendages acting to protect the body from various kinds of damage, such as loss of water or damages from outside. The integumentary system includes hair, scales, feathers, hooves, and nails.

Psychiatric

ADD, ADHD, anxiety, bipolar disorder, depression, OCD, substance dependancy and general notes.

A psychological disability or psychiatric disability refers to a spectrum of mental disorders or conditions that influence our emotions, cognitions, and/or behaviors. 

Neurology

Cranial, dermatomes, reflexes, sensory system, motor system and general notes.

The nervous system is made up of two parts: the central and peripheral nervous system and deals with disorders of the nervous system. It includes the brain, spinal cord and nerves.


Diagnosis & Plan

Diagnosis and Plan assists in planning the patients treatment and recovery. Assisting in the following:

  1. Quick once-off diagnosis
  2. Easy guided custom procedures
  3. Single click invoicing and direct scripting
  4. The treatment plan can be built and will assist in knowing what to expect and when important dates for follow-ups are necessary


Advanced Features

Here are some advance features that can assist the practitioner in capturing important information correctly and easily. These features are applicable to each section:

  1. Add images to any section of the form
  2. Use your phone as a clinical camera
  3. Make annotations on any image
  4. Download, email or print the form


Quick Note

The quick note can be used to make short notes and add pictures, when a practitioner does not want to use the General Examination form. It can also be used to capture any additional information about the patient examination.


Use a phone as a Clinical Camera 

  • When the practitioner needs to take a photo of an injury or wound, the practitioners personal cellphone can be used to take the photo and be uploaded immediately onto the patient electronic file under the clinical information. 
  • The function will delete the original photo from the practitioner’s personal phone while uploading the photo to the patient’s file. 
  • This will assist in keeping the patient privacy.
  • Notes and drawings can be made on the photo and be saved. 
  • The photos can be used to indicate the process of the wound or injury.