Completing the Objective Section of IE

Completing the Objective Section of the Initial Evaluation

The Objective section is sub-categorized in the following areas:

Observation
Range of Motion
Strength
Neurological
Joint Mobility
Flexibility
Palpation
Special Tests

This section was built in such a way so that there is no required elements. However, this section is entirely template based. As you build your template validation requirements for this section will be built as well.

Sub-Categories are provided to organize the information for your Templates.

Each section can be opened by pressing the Expand arrow for that section.

Each section works similar in fashion, each sub-category allows you to perform the following tasks as you fill out a current Initial Evaluation OR when you are building your templates:

Create Measurements
Create Tables
Create Structured Range of Motion/ Strength Tables (Only available in Strength and ROM categories)
Flag issues as Problems
Write Section Based Problems
Add Section Based Comments

In the following pages we will go over how to preform these tasks and provide an example of what a section might look like with a template.

Create Measurements using the Creation Tool this is located at the top of ALL sub-categories.

Select the Data Type of Create Measurement
Assign a Label in the Enter Label Free Text area for the measurement you wish to create.
Select Element Types that you wish to include, an explanation of each is listed below:
- Number- a numeric free text area with an option to include a label. You may also assign an orientation if applicable to report on only right, left, or both sides.
- Multiple Choice- a list of preset choices displays for your measurement to make for easy assignment. You may also assign an orientation if applicable to report on only right, left or, both sides.
- Free Text- have a Free Text area included for the measurement
You may choose one or multiple element types to include for your measurement. Below is an example that used ALL the available element types.
Click the Add button to create the measurement
The Measurement will display below. If added, only one of the elements is required to be filled out to fulfill the validation.
To include the findings from this measurement in the Narrative Problems List of the Assessment section click on the Flag icon.

**Note: Only flagged items will pull to the PDF version of the Initial Plan of Care.

Create Tables using the Create Tool that is located at the top of ALL sub-categories.

Select the Data Type of Create Table
Enter a title for the table in the Enter Title Free Text area provided.
Enter the Column Amount needed for the table. Rows will be added AFTER table creation.
Click the Add button to create the table.
The Table will be added below. You will need to assign Column Titles and add some applicable rows by pressing the + icon on the Last Row.

**Note: By keeping row information generic, you can use the tables as Templates and then fill out accordingly for a Initial Evaluation. Please see the example below.

Strength and Range of Motion sub-categories have an additional feature called a Structure Table.

The Structured Table has a set of Predefined Measurements in the database for easy addition.
Measurements included in the Structure Table may be tracked throughout the duration of care under the Objective Findings Table in the Assessment of the Initial Evaluation and future Progress Notes/ Discharge Summary documents.
Goals will be assigned to these values in the Assessment section and will auto-calculate Goal Percent on Progress Notes/ Discharge Summary documents.

Structure Tables for Strength and Range of Motion will display by default (unless a Template is used)

The primary Body Region will pull from the Header of the Initial Evaluation document.
Select the Measurements from the drop down menu for that Body Region. Select ALL that apply.
Click on the Add button to add the Selected Measurements.
The Selected Measurements will display in the Structured Table.

Add another Body Region Structured Table by:

Selecting the New Body Region in the Primary Structured Table.

Select the Measurements from the drop down menu for that Body Region. Select ALL that apply.
Click on the Add button to add the Selected Measurements.
An Additional Structure Table for that Body Region will be added below the Primary Structure Table.

**Note: Structured Tables may be saved to Template as well so that Common Measurements display by default. You will only need to edit/ modify as necessary for that patient.

To fill out a Structured Table, you will only need to fill out ONE of the available fields within a row to fulfill the validation requirement. If it doesn't apply to the patient, use the Delete button to remove the Row.

You may also mark the body region as No Limitation Noted as applicable using the No Limitation Checkbox.

If you want to track a Structure Table Measurement throughout the duration of care:

Flag the measure by clicking on the Flag icon next to it. This will be added to the Objective Findings Table in the Assessment section to be tracked on future documents.

Section Based Problems are available for you to write narrative problems for that section by:

Typing in the Free Text area provided in each sub-category.
Section Based Problems are flagged by default to be added to the Narrative Problems List in the Assessment section.
- To unflag, click on the Flag icon to remove it from the list.

**Note: As mentioned before, everything in the Objective section can be included on your Template.

Section Based Problems are a great area to include basic Narrative Problems so that you may assign Goals within the Assessment section prior to filling out the Initial Evaluation.
This increases efficiency by allowing you to only have to edit/ modify information as necessary.

Additional Comments by section may be entered by:

Typing in the Additional Comments Free Text area provided at the bottom of all sub-categories.