Exam

The detailed examination screens. Where Objective records your findings on the spine visit by visit, these produce standalone examination reports — the documents you perform at an initial visit, a re-evaluation, or when a specific question needs answering.

Screen	Records
Ortho/Neuro	Orthopedic and neurological signs and tests
Range of Motion	Measured ROM against normal values
Physical	Vital signs, posture, head, heart, lungs, growth
Imaging	The Diagnostic Imaging Report
Sensory	Tendon reflexes, manual stimulation, dermatomes, nerves
Muscle	Muscle strength testing
Extremity	Findings on joints and bones outside the spine

What they have in common

These screens differ in content but behave the same way in the ways that matter.

Starting a report

Each starts a new report dated today, pre-filled from your preferences for that screen. Those defaults are yours to override on any individual report.

Getting the report into today's note

Two conditions, both required

An examination appears in today's SOAP note only if:

1. its exam date is today, and
2. it was completed before the note was generated

Miss either and the report is still saved — it just is not in that note. If you have already generated the note, regenerate it after completing the exam.

Amending a saved report

Saved reports are amended by addendum, never edited

Once saved, an examination report cannot be quietly changed. Corrections and additions go in as an addendum, which records the date, the original report's date, who is making the entry, the addendum text, and the reason.

That format is required at both state and federal level — and the immutability is the point. A report nobody can alter after the fact is a report nobody can accuse you of having altered.

What reaches the note

Each screen offers a choice between putting the entire report into the SOAP note or selecting specific sections. Set it as a preference and override per report.

On saving, ChiroPad turns your point-and-click entries into readable prose, which you can then edit before committing.

Documenting thoroughly

Incomplete examination records are a real exposure

State and federal statutes expect examination findings to be documented as completely as the examination allows. Where a file is reviewed — by an insurer or anyone else — and the documentation is found incomplete, the consequences run to demands for refunds of fees paid, fines, and allegations of fraud.

The screens will let you save a sparse report. That is not the same as it being defensible.

Where these fit in the PART exam

Medicare's PART exam has four elements, and they are spread across two places:

Element	Recorded on
P — Pain / tenderness	Objective
A — Asymmetry	Objective — subluxation listings or fixation
R — Range of motion	Range of Motion
T — Tone, texture, temperature	Objective — tonicity, temperature, edema

Which letters you report on a claim is set on the patient's policy — at least two, one of which must be A or R.