The method of entering data is the same for each of the findings regardless of the vertebral level. Click on the appropriate symbol so it is highlighted, then click on the spinal level(s) that the finding(s) is located at. The symbol, together with any selected Adjective Symbols will be displayed in the Spinal columns. As soon as the initial entry has been made, ChiroPadEMR/ChiroSuiteEHR retains the memory of the entry. On each subsequent visit, it will be easy to see what was done on the prior visit.
For data entry purposes, the middle column should be thought of as 3 sections.
1. Pain, Edema, Temperature and Tonicity is the first section. Select any single or combination of items within this box and click on the spinal level(s) that those items apply to. For findings that are only on the right or left, click in the side column. When the items are bilateral, click on the spine.
2. Subluxations and Adjustments, Fixations, and Adjustment Technique Indicators comprise section 2. Select any single or combination of items within these boxes and then click on the spinal level(s) that those items apply to. For findings that are only on the right or left, click in the right or left column. When the items are bilateral, click on the spine itself.
3. Additional Information text box is the third section. Information entry can be done by [a] typing it in, [b] drag and drop from Paraphrase, [c] cut and paste from a word processor, [d] dictate using Dragon Naturally Speaking and [e] on a tablet computer that has handwriting recognition, write it in and the tablet will convert it to typewritten text.
Adjective Symbols are shown on each line next to the finding symbol. The Adjective Symbols are standardized, that is, they mean the same thing regardless of which finding they are associated with.
•$ shows that there has been no change in the finding
•* verifies that NO verbiage will be entered for that finding and, if that finding had previously been entered, it removes the finding from the spinal display
•0 notes that the finding is NOT present
•c shows that the finding is reduced or decreased
•5 shows that there has been no change or variation in the finding
•_ shows that the finding is increased, more intense or worse
•1 demonstrates that the finding is mild
•2 demonstrates that the finding is moderate
•3 demonstrates that the finding is severe
•4 is used only in the tonicity finding. It demonstrates that the finding is spasm if hypertonic and flaccid if hypotonic