The physical examination is an essential part of any interaction with the patient. It is also quite a complicated set of activities that are usually tied to a particular group of body systems. The variety of findings from these multiple body regions can be time consuming and cluttering to list on a computer, whereas with pen and paper it is usually much faster to jot down a few diagrams and move on. Everyone has their own unique way of recording this data. Finally, the benefit of recording an examination in a systematic rather than individual way does not seem to provide additional benefits to staff or patients - it just takes more time.
For this reason I have found the physical examination component of any EMR software to be the most cumbersome and difficult to implement.
Example - Breast Examination
Breast cancer is the most common radically treated malignancy in radiation oncology. Therefore breast examination is likely the most commonly performed physical examination. What is the examiner looking for?
- Mastectomy (none, left side, right side, both)
- Symmetry (size, shape, pigmentation, radiation effect, nipple inversion)
- Scars (may be peri-areolar, wide local excision, merged with axillary scar, mastectomy scar)
- Reconstruction (may be expander, silicone, rotated flap)
- Mass (may be multiple, size, texture, skin involvement, fixation to chest wall, position in breast (quadrant, clock face, distance from nipple), relation to previous surgery)
- Cosmesis (some scale, 'good' or 'bad')
- Other features (peau d'orange, Paget's disease)
The breast examination is usually but not always coupled with a regional nodal examination (axillary, supraclavicular), respiratory examination, and upper abdominal examination which all have their own aspects.
Options for Data Entry
Free text
The method which may appeal to some doctors is to have a free text box where they can type or dictate their clinical findings into.
- Advantages: Less complicated to implement, less of a burden to teach doctors how to use
- Disadvantages: No scope for diagrams, data is not standardised
Standardised entry
For each examination, a set of standard response would be allowed. There may be a free text option if the clinical finding is not included in the standard responses.
- Advantages: Standardised data entry to allow for comparison of data, diagrams could be included, may be faster than typing everything in, potentially generates a readable English description for a letter
- Disadvantages: May be more time consuming if complicated, lack of flexibility, screen may be overwhelming especially for those not familiar with computers
For example, if you entered in "Left breast - Mastectomy - Skin Sparing", "Right breast - No abnormalities", the software should be able to generate "The patient has had a left skin sparing mastectomy. The right breast was normal with no abnormality on inspection or palpation". It could then include the statement in a letter to the referring doctor. This simple example would definitely save the doctor time and would obviate the need for a typist.
A more complex example would be if the patient had a mass in the mastectomy scar. There would need to be multiple check boxes: "Left breast - Mastectomy - Skin Sparing" as well as scar features / position, mass features (ulceration, position, size, fixation). Things would be more complicated if there were multiple masses. In these situations it would be much easier to sketch a diagram and dictate "There were multiple ulcerating masses within the left mastectomy scar" than tick a host of different buttons. The fact that these are possible options makes the entire screen seem cluttered, even when the examination was relatively simple.
