Examination Findings Summary

From the navigation pane of the Patient Record, right mouse click on Examination Findings and select Summary.

Right click against the line where you want to add data and select Add.

Temperature - The default READ term is 2E3..11 O/E - temperature level. You could also choose 2E2 O/E - method fever registered, 2E3 O/E - level of fever.

Weight and Height. The BMI refers to Body Mass Index. If both the height and weight have been recorded, the BMI will automatically be calculated by dividing the weight in kg by the height ² in m.

Weight loss - The READ term is 22A8 Weight loss from baseline weight.

Waist Circumference - The READ term is 22N0 Waist measurement.

Pulse (CVS/BP) - Enter a pulse rate, select a suitable READ term from 242 O/E -pulse rate, and make any notes on rhythm.

BP and JVP - See BP and Hypertension section.

Postural drop in BP - 2468 O/E - BP - reading postural drop

Target blood pressure - Either246L Target diastolic blood pressure, or 246K Targetsystloic blood pressure.

Ankle brachial pressure index (APBI) - 585a ABPI - Ankle brachial pressure index (default), 585b Left dorsalis pedis ABPI, 585c Right dorsalis pedis ABPI, 585d Left posterior tibial ABPI, 585e Right posterior tibial ABPI

Pretreatment BP (CVS/BP) - 6623 Pre-treatment BP reading.

Heart Exam. - Select a READ term, the default is 24... 00 Exam of cardio-vascular system. In Rhythm, and Size/Failure, and Sounds, the default is <None>, but you may also choose Normal or Abnormal.

Foot pulse left/right leg - In sequence, the right foot pulse screen is shown before the left. Otherwise, from the front screen, click either on Left or Right. At the Foot Pulses screen, the default READ term is 24E.. 00 O/E - peripheral pulses R. leg. Other choices include: 246EA O/E - absent right foot pulses, 24EB O/E - right foot pulses present, 24EC O/E - Right dorsalis pedis abnormal, 24ED O/E - Right posterior tibial pulse abnormal, 24EZ O/E - R.leg pulses NOS, 24E1 O/E - R.leg pulses all present, 24FA O/E - Absent left foot pulses, 24FB O/E - Left foot pulses present, 24FC O/E - left dorsalis pedis abnormal, 24FD O/E - Left posterior tibial pulse abnormal, 24FZ O/E - L.leg pulses NOS, 24F1 O/E - L.leg pulses all present.

Pulse oximetry - 8A44 Pulse oximetry monitoring, 8A44.11 Pulse oximetry (default)

Foot care - The default READ term is 2G5 O/E - foot, but other options are its hierarchical codes, 2G6 O/E - toe and hierarchical codes, andalso 66AE Feet examination.

Peripheral oedema - Select a READ term, if required, other than the default R0234 00 [D]Peripheral oedema. In Peripheral oedema, the default is <None> and the choice also Absent or Present. Optionally choose Laterality (None, Left, Right, Midline, Indeterminate, Bilateral) and Site of oedema (None, Toe, Foot, Ankle, Lower leg, Whole leg).

Ankle neuropathy - The READ term default is 29H1 O/E - vibration sense normal. Select also from 29H O/E - vibration sense (and hierarchical codes) and 2A4 O/E- ankle reflex (and hierarchical codes). There are options for Left jerk, Right jerk, Left ankle vibration sense, Right ankle vibration sense - None, Normal, Absent, Diminished, Increased, Not examined.

Tactile sensation - The READ term default is 29B1 O/E - tactile sensation normal. Select from other hierarchical codes of 29B O/E - tactile sensation and also 311A Monofilament foot sensation test.

Visual acuity left/right eye - Select from2B6 O/E - visual acuity R.-eye, 2B61 O/E - visual acuity R.-eye =6/5, 2B62 O/E - visual acuity R.-eye =6/6, 2B63 O/E - visual acuity R.-eye =6/9, etc

2B7 O/E - visual acuity L.-eye, 2B71 O/E - visual acuity L.-eye =6/5, 2B72 O/E - visual acuity L.-eye =6/6, 2B73 O/E - visual acuity L.-eye =6/9, etc

Fundoscopy - Select a READ term 3128 Fundoscopy, 2BA O/E - optic disc inspection, 2BB O/E - retinal inspection. In Result, select <None>, Normal or Abnormal.

PF current - see Peak Flow

Respiratory rate - The default READ term is 235 O/E - rate of respiration.

Breast examination - The default READ term is 26B O/E - general breast exam but you can select from other hierarchical codes. Note that 26B2 O/E -gynaecomastia, entered for a male patient, is not included under Breast Examination and can be added in READ Term Add, or History Add.

Pelvic examination - The READ term is 277 O/E - VE for pelvicassessment.