10.3.4.1. Short Exam

The standard exam includes the basics when assessing if a patient is a surgical candidate.

It includes the exam vet, TPR, and general SOAP notes.

Short Exam Sections

• TPR: Notate whether the TPR is not within normal limits. HQ automatically has these sections set to normal, so you only need to notate if there is an abnormality.
• Subjective: Note if the patient passes the BAR test.
• Objective: If the exam was not normal or If a full exam could not be completed, you can mark Could Not Exam. The options Loud Purring, Could Not Handle, and Other can be selected.
• Assessment: Surgical Candidate: Indicate if the patient is not a surgical candidate.
• Plan: Surgically Sterilize: This is where you can decline a patient for surgery before administering meds. To decline, select Decline, then select the No Surgery Reason.

Note: By default, all categories are set to normal to speed up the recording process. If any section is marked abnormal, the system will tag an abnormal exam to notify the team.

This will display in the “Exam” section for your team to view:

The High Risk Waiver

If a high risk waiver is necessary, click Request High Risk Waiver under the standard exam section. This will push the patient to the HRW tab in Patient Flow where you can complete the request. To learn more about high risk waivers, go here.