How to document Functional/Cognitive status in an exam

1. Open the Exam > Scroll to Physical Exam > Click Findings

2. Click the Functional/Cognitive button at the top of the menu

3. Click Add

4. Search by description or SNOWMEDCT code > Double click to select condition

Star your usual findings for normal and abnormal as favorites, so that they are readily available going forward.

 

5. Update Type and Date > Click Done

6. Click Done, then Save your physical findings

You do need to document normals for certain E&M coding.

7. Your documentations will drop into the exam

Alternatively, Functional / Cognitive status can be imported from defaults if you've enabled them in the Exam Defaults menu of the Configure section of the EHR. If you have enabled that default, simply begin by clicking the "Default" option from Func / Cogn at the top of the menu, then select your chosen default and click DONE to save.