Body charts
Marking pain with a 0–10 score, stiffness, swelling, pins and needles and more on the whole body, shading a spread, and comparing visits.
Adding a body chart
Open a clinical note you're writing and press Body chart under Body chart and MSK assessments (or use the body chart in your note template). You'll see the whole body from the front and the back. From the front the patient's right is on your left, as when you face them; from the back their left is on your left. Each side is labelled. On a phone you see one side at a time: press Front or Back to switch.
Tap where the finding is: the head and neck, a shoulder, upper arm, elbow, forearm, wrist and hand, the chest, abdomen, thoracic or lumbar spine, the pelvis and sacroiliac joint, a hip, thigh, knee, lower leg, or the ankle and foot. Choose What it is: pain, stiffness, swelling, numbness or pins and needles, weakness, referred pain, an injury or scar, or something else. Pain and referred pain take a pain score from 0 (none) to 10 (the worst imaginable): tap the number. Press Add to the chart. A marker with a short code (P for pain with its score, St for stiffness and so on) appears where you tapped.
Every change is saved with the note straight away. Tap a marker, or Change in the list below the drawing, to change or remove it.
Shading a spread
For referred pain or a dermatome-like spread of pins and needles, press Shade an area, choose what the shading shows, and draw with your finger or the mouse. While shading is on, the page doesn't scroll under your finger. Undo last takes off the last stroke; Clear shading takes them all off. Press Mark findings to go back to tapping.
The feet, close up
The ankle and foot open the foot chart: tap the ankle and foot, then Open the foot chart, to mark the feet in detail (callus, nails, ulcers and the rest). It's saved with the same note, and the body chart shows how many findings the foot chart has, so physiotherapy and podiatry share one picture. See the foot chart article for more.
Next time, and over time
On the next note, Start from the last chart copies the last chart's findings and shading, so you only update what changed (tap a marker to change its score). The patient's record shows the latest chart under Body chart and MSK, with the worst pain score's trend ("Worst pain down from 8 to 3 over 3 visits"). Compare and see trends shows any two visits side by side, with what's new, still there (with the score before and now) and gone, a chart of the worst pain over time, range of motion over time and outcome scores.
Signing and printing
The chart is locked when you sign the note; to correct it, amend the note (the amendment starts with a copy). The body chart page has Print or save as PDF.
Who sees it
Like clinical notes: clinicians and the owner, never reception. Everything is encrypted with your clinic's own key and every view is recorded in the audit log. It's in the patient's subject access export and the clinic's data download.