Continued Education

When a patient presents with back pain, we hope that they don't have one of the "scary" diagnoses. Some of these would include cauda equina, spinal cord injury or compression, a spinal cord abscess and many more. While most back pain is related to a musculoskeletal problem, without the documentation to support the lack of "back pain red flags," our charting has gaps in it. Remember- if it is not documented, it is not done.

One of our EPIC cheat sheet dot phrases, .sahpiriskbackpain, includes all of the red flags that are associated with those severe back pain diagnoses. This is as follows:

"The patient denies having any numbness, tingling, focal weakness, saddle distribution anesthesia, bladder/bowel incontinence, urinary retention, fever, or IV drug use."

We need to be editing this to only include what is asked, but this will greatly help you with speed and accuracy.

Physical Exam for back pain complaint -

Every subjective complaint has an objective evaluation. So, anytime back pain is mentioned in the HPI, we will usually have a complete back exam. This includes documentation on the midline spine (tenderness, step offs, deformities,) and you may also include a paraspinal musculature exam. The "back" includes your CTLS spines (cervical, thoracic, lumbar and sacral) and we often insert the c-spine exam into the neck region, while the TLS spines are examined in the back section. When read head to toe we often will insert the back exam below MSK.

Additionally, we will often do a more in depth neuro exam for a back pain patient and it is important to document the strength, sensation, reflexes and gait of these patients. DTR = deep tendon reflexes... if they don't assess all 5 reflexes then you need to delete this and insert the reflexes they do examine (often patellar and achilles.)

You may use the PE dot phrase as below, .sapeback:

Neck:　 Supple. No cervical midline bony tenderness, deformities, or step-offs.

Back: No*** midline bony tenderness, deformities, or step-offs of the thoracic or lumbar spine. 　 No abrasions or bruising. No erythema, induration or fluctuance.

Neurological: Alert, awake, and appropriate***.　Negative straight leg raise bilaterally***. Normal perineal sensation and anal tone***. 5/5 strength bilateral lower extremities upon knee flexion/extension***, ankle dorsi-flexion***, ankle plantar-flexion***, great toe extension***.　 No sensory deficits to light touch***. *** DTR’s 2+ and equal.　 Normal gait. Normal heel and toe walk***.

Extremity Exams

How to document a full extremity exam!

In classroom training, we discuss the ABC's of life and the CSMT's of extremities. You may remember that the definition of critical care is a threat to a life or limb.... by documenting that the patient's ABC's and CSMT's are intact, we are providing support that they are not in critical condition.

Below you will see examples of how each one of these vital findings can be documented within the PE of your chart:

Documenting the ABC's of life-

Airway. - Airway intact. Talking.

Breathing- Spontaneous breath sounds. Clear to auscultation bilaterally. No decreased breath sounds.

Circulation- Radial, femoral, DP and PT pulses are 2+, symmetric.

^^ Because of the ABCs, each patient will always have a cardio/pulm exam and that is why we learn the FTD findings for these even if they don't auscultate.

Documenting the CSMT's of extremities:

Circulation- Radial, femoral, DP and/or PT pulses are 2+, symmetric. Capillary refill intact. The extremity is warm and well perfused.

Sensation - Distal sensation to light touch intact ...to the LLE, to the right hand, x4, etc.

Motor/Tendon- FROM, Strength is 5/5 with ... flexion/extension, grip strength, plantarflexion/dorsiflexion, etc.

Your physician will assess all four (CSMT) of these criteria on every single patient with an extremity complaint.

They may call out "left foot exam is normal." At this point, you can use the tools and knowledge you've gained through this email and from classroom training to prompt them for clarifications on the individual findings:

If the provider says, "left foot is normal," then you may document the full extremity exam and/or clarify by responding with "Great, so I can document- LLE: strength 5/5, FROM, sensation to light touch intact and DP/PT pulses are 2+?"

For any exam (normal or abnormal) if one of these findings is not called out, you can now prompt them for-

Circulation: "Did you assess pulses, or would you like me to document capillary refill?"

Sensation: "Did the patient have intact sensation?"

Motor/Tendon: "Did you assess strength and/or ROM?"

Of note- FROM = Full Range of Motion. This can be assessed via passive or active ROM. They may specify further.

To assist in documentation of extremities, you may now use .sapeextremities which will pull in the text below so that you have all of these findings and can easily prompt the provider for what you need:

RUE: No*** deformities. Full ROM***. There is no bony*** tenderness. Distal sensation intact ***. Strength is 5/5 ***. Radial pulse 2+.

LUE: No*** deformities. Full ROM***. There is no bony*** tenderness. Distal sensation intact ***. Strength is 5/5 ***. Radial pulse 2+.

RLE: No*** deformities. Full ROM***. There is no bony*** tenderness. Distal sensation intact ***. Strength is 5/5 ***. DP/PT pulses 2+.

LLE: No*** deformities. Full ROM***. There is no bony*** tenderness. Distal sensation intact ***. Strength is 5/5 ***. DP/PT pulses 2+.

Lastly, we have a multitude of .sapeortho dot phrases that assess specific joints- you should still be using these if a provider does an extensive exam on any of the joints. Remember that dot phrases are meant to help you but should be edited. If you pull in .sapeorthoknee but the provider doesn't do anterior/posterior knee testing then you should be deleting this part. The same goes for any other specific testing in the dot phrase.

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