The Objective is where we start gathering specific details about a patient's medical history. You’ll be able to:
Add, edit, or delete vitals
Add a physical exam
Compare multiple sets of vitals
Vitals
Here's where you'll enter vitals collected. Click + Add Vitals to log:
Weight and unit (lb, kg, g)
Temperature (F or C) and temperature location
Pulse
Respiratory rate
Mucous Membrane Color and Hydration
Capillary Refill Time
Attitude
Mentation
Blood pressure (if activated) (Systolic/Diastolic (MAP))
Notes
Once the vitals have been saved, they’ll populate at the top of the Objective with a timestamp. If you have more than one set of vitals, you can toggle between them using the timestamp dropdown. You can also compare multiple sets of vitals in the comparison table explained below.
Did Not Obtain
If you did not obtain vitals (in general) or certain vitals (temperature, CRT), you can mark them as Did Not Obtain (DNO). When reviewing historical SOAPs or exporting records, these vitals will be listed as Did Not Obtain.
Blood Pressure
To include Blood Pressure fields as part of Vitals, navigate to Admin -> Clinic Settings -> Settings -> SOAP, and enable the toggle for Include Blood Pressure fields on vitals.
When activated, Blood Pressure fields are available with your vitals area. MAP is automatically calculated for you based on Systolic and Diastolic entries.
Physical Exams
Shepherd allows for different kinds of physical exams to be given to a patient depending on their needs. Shepherd has pre-loaded standard exam templates, but you can also create your own custom templates! Learn more about that here.
Click the Add Physical Exam button which will provide you with a list of your physical exam templates to select from.
Once the exam is selected, assign a supervising doctor, and proceed through the exam fields.
Adding a Body Map
Select Add Body Map to populate a new field at the bottom of the physical exam template. Select the appropriate body map from the dropdown and mark it up as needed!
Once you’ve saved the exam to the patient’s medical record, it will populate within the Physical Exam section. If you’re performing multiple exams during a patient’s visit, you’ll be able to toggle between them via a dropdown in the upper-left corner of the Physical Exam section.
Comparison Table
Compare multiple sets of vitals
In this section of the Objective page, you can track up to 10+ sets of vitals (depending on screen size), allowing you to note any changes at a glance.
