Exam Sheets

[atd]

Wondering if most people are using the Exam Sheets or entering everything in their procedure notes (using auto notes). We currently have a lengthy set of prompts using auto notes for exams and are looking into implementing an exam sheet instead. It would be similar to the form we used when we were on paper charts, so I'm wondering if this is a step backwards or would actually be better documentation for exams.

Some questions that have come up regarding using an exam sheet are:
- Do you need to have a Yes/No for every option on the form or can you just use check boxes for things you do find and use WNL or N/A when problems are not found?
- Does checking a box on a form hold up as well legally as typed out notes (even if created using an auto-note)?
- Is it faster to use an exam sheet or auto-notes?

Would anyone be willing to share what their exam sheets look like for comparison?

Thanks

[jordansparks]

We make use of the exam sheets feature for some of our internal processes. It's a great way to have a checklist. It's a living document, because you can frequently make changes so that it's slightly better for the next patient. I love features that are iterative like that.

[atd]

I agree with the benefits from a usability standpoint, but I'm wondering more about how checkboxes vs notes hold up legally.

As for my question regarding the use of Yes/No vs just checking if there's a problem or choosing WNL, here's a specific example of the Intra-oral Exam:

Paper Form
Intra-Oral Exam
[Y] [N] Mucosal Lesions
[Y] [N] Xerostomia
[Y] [N] Exostoses
[Y] [N] Epulis
[Y] [N] Candidiasis

I'm trying to avoid the need for them to click on the N 5 times if there are no problems, by incorporating a WNL. Then they would only check the other boxes if there was a problem. One of our dentists thinks that you need to check either Y or N as we did on the paper form to show that you actually looked at all of those things. Here is what I was proposing for the Exam Sheet, which is actually based on how we do our Auto Notes.

Proposed Exam Sheet
Intra-Oral Exam [ ] WNL
[ ] Mucosal Lesions
[ ] Xerostomia
[ ] Exostoses
[ ] Epulis
[ ] Candidiasis

How are other people setting up their exam sheets?

[jordansparks]

We're not as rigorous about locking exam sheets. There is a "lock" feature when you sign, but it can be overridden by an Admin. I'm guessing that it won't be too long before we have a "snapshot" button on sheets that will let you save an unalterable copy. This would be useful for repeated changes. Until then, backups are a good way of proving that records were unaltered.

[KevinVan]

Has there been in improvement or the snapshot of the exam sheet?

Thanks
Kevin