Shepherd is designed to save you time, including with medical record documentation. A few key functions of the physical exam templates are the ability to have default values pre-loaded to reduce the amount of typing needed and the ability to import previous exams into new SOAPs, again to save more time from typing the same patient's info twice.
To get started, we've preloaded some exam templates for you to use. You can use these as is, edit them, or even create new ones.
Note: doctors may want to create their own exam templates since everyone writes records a bit differently. Based on user role permission, you can enable different users to have access to the exam templates.
To access the Physical Exams section, navigate to Admin -> Physical Exams
Creating a New Template
To add a new physical exam, select the +Add New button on the right side of the screen. Be sure to give your exam template a title by selecting Add Title in the left-hand corner.
Adding a Field and Input Elements
The next step is to add a field and then within the field(s), you will add an input field(s). Think of fields as placeholders where you want the information to go and the input fields as what information you want to go there. Input fields can have pre-populated text or be set up as blank fields to use when using the exam.
Select the +Add Field button
Add a field title by selecting/clicking on 'Untitled Field' and enter the title under Field Name on the right-hand side
Select < Done to go back to the input fields
Now that you have a field, you can one or more input elements into that field.
Select and drag the input element into the field box
Depending on the input type, you will be able to add additional input options such as drop-down menu options, radio button select options, and more. To edit additional information on the input element, select/click on the input and that will bring up an additional editor on the right-hand side.
You can continue to add more fields and input elements as needed to complete your template.
Multiple Input Elements
Adding multiple input elements to a field allows you to have the option of having options like ‘Normal,’ ‘Abnormal,’ and ‘DNE’ for a field while also having a notes section for when any further explanation is required.
Template Default Values
After adding your input elements, you can set the default values for those elements by selecting the radio button you want to have selected by default, entering the text you want to be displayed by default, etc.
For example, in the image below under Appearance, 'Normal' will be selected by default, and the text 'Within normal limits' will automatically populate when this template is loaded into a new SOAP. You could select 'Abnormal' and that would be selected in a new SOAP instead of 'Normal'. Note: regardless of any defaults from the template, you can edit the exam as needed within each SOAP.
Preview Physical Exam
Previewing the exam allows you to see the fields and default values that will load when this template is used within a SOAP.
Copy Physical Exam
Copying an existing physical exam is a great way to save time when making a new exam template.
Customizing the exam template is where you will be able to create the templates (using fields and input elements) and set default values that will automatically populate when you load this template into a new SOAP. If you have an existing exam template you want to edit, you will select Customize and make any of the necessary changes. (Don't forget to save your changes when done!)
Archive Physical Exam
If you no longer want to use an exam template, you can archive it. You can unarchive in the future if needed.