Physical exam - Occipital neuralgia / cervicogenic headache

Form ID: exam_occipital_neuralgia Type: Physical Exam Family: Physical Exam

Structured fields

Section	Field	Key	Default layer	Required	Quick text templates
Header	Clinician	`clinician_name`	Global Default	Required
Header	Encounter date	`encounter_date`	No Default	Required
Header	Condition focus	`condition_focus`	Per-Form Default	Required
General	General appearance / relevant vitals	`general_appearance_vitals`	No Default	Optional
Observation	Gait, posture, and movement observation	`gait_posture_movement`	No Default	Optional
Inspection	Inspection	`inspection_findings`	No Default	Required
Palpation	Palpation / tenderness / trigger points	`palpation_findings`	No Default	Required
ROM	Range of motion	`range_of_motion`	No Default	Required
Neuro	Strength, sensation, reflexes / neurovascular status	`strength_sensation_reflexes`	No Default	Required
Provocation	Condition-specific exam maneuvers	`condition_specific_exam`	Per-Form Default	Optional
Safety	Red-flag exam findings / escalation triggers	`red_flag_exam_findings`	No Default	Required	Reviewed today and no patient-specific contraindication identified.; Patient-specific exception documented in the free-text field.
Procedure planning	Procedure target assessment and image correlation	`procedural_target_assessment`	No Default	Optional
Assessment	Pain generator impression	`pain_generator_impression`	No Default	Required
Assessment	Exam safety/context phrase	`exam_safety_phrase`	Global Default	Optional
Plan	Exam-based plan / next steps	`exam_plan`	No Default	Required

Section

Field

Key

Default layer

Required

Quick text templates

History/exam sources

Header

Clinician

clinician_name

Global Default

Required

Header

Encounter date

encounter_date

No Default

Required

Header

Condition focus

condition_focus

Per-Form Default

Required

General

General appearance / relevant vitals

general_appearance_vitals

No Default

Optional

Observation

Gait, posture, and movement observation

gait_posture_movement

No Default

Optional

Inspection

inspection_findings

No Default

Required

Palpation

Palpation / tenderness / trigger points

palpation_findings

No Default

Required

ROM

Range of motion

range_of_motion

No Default

Required

Neuro

Strength, sensation, reflexes / neurovascular status

strength_sensation_reflexes

No Default

Required

Provocation

Condition-specific exam maneuvers

condition_specific_exam

Per-Form Default

Optional

Safety

Red-flag exam findings / escalation triggers

red_flag_exam_findings

No Default

Required

Reviewed today and no patient-specific contraindication identified.; Patient-specific exception documented in the free-text field.

Procedure planning

Procedure target assessment and image correlation

procedural_target_assessment

No Default

Optional

Assessment

Pain generator impression

pain_generator_impression

No Default

Required

Assessment

Exam safety/context phrase

exam_safety_phrase

Global Default

Optional

Plan

Exam-based plan / next steps

exam_plan

No Default

Required

Narrative template

Physical examination template: Occipital neuralgia / cervicogenic headache
Clinician: {{clinician_name}}. Date: {{encounter_date}}.

General/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.

Condition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.

Pain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}

Physician review required before signing in the EMR. Verify actual medications, doses, lot/expiry, devices, image documentation, response, complications, and follow-up.