Orthopedic cases: the body map

What this does

Orthopedic cases in Usystems let you document injuries, pain, and clinical findings related to bones, joints, muscles, and ligaments. A key feature is the 3D body map—an interactive visual representation of the human body that you can click to mark exactly where on the body the injury or complaint is located. This creates a precise clinical record that supports diagnosis, treatment planning, and accurate billing.

Before you start

• You have permission to create medical cases. If you see "Access denied" when opening a medical record, contact your administrator.
• The patient already exists in Usystems and has a medical record open.
• You have a clear clinical reason for the orthopedic case—for example, a fracture, sprain, joint pain, or post-surgical follow-up.
• The procedures or services you plan to document (e.g., "Orthopedic Exam," "X-ray," "Physical Therapy") are set up in your service catalog.

Steps

1. Open the patient's medical record. Go to Medical Cases Open in Usystems and find the patient. If they don't have a medical record yet, create one first.

2. Click Create New Case or the plus (+) button. A dialog appears listing available case types (Dental, Neurosurgery, ENT, Orthopedic, etc.).

3. Select Orthopedic as the specialty. The Orthopedic case template opens, showing a 3D body map and fields for recording findings.

4. Describe the chief complaint or reason for visit. Enter the patient's main symptom—for example, "Right knee pain," "Fractured left ankle," "Post-surgery check (right shoulder)," or "Chronic low back pain."

5. Click on the body map to mark the affected area. The 3D body map shows the front and back views of the human body. Click on the area where the patient has pain, injury, or complaint:

   • Click the head for head/neck injuries
   • Click the arm, elbow, wrist, or hand for upper extremity issues
   • Click the torso for back or trunk issues
   • Click the leg, knee, ankle, or foot for lower extremity issues

   You can click multiple areas if the patient has more than one complaint (e.g., both knees affected).

6. Record clinical findings for the marked area. Depending on the template, you may enter:

   • Type of injury (fracture, sprain, strain, contusion, dislocation, etc.)
   • Severity (mild, moderate, severe)
   • Imaging results (if X-ray, CT, or MRI was performed)
   • Physical examination findings (range of motion, tenderness, swelling, deformity)
   • Associated symptoms (numbness, tingling, weakness)

7. Add procedures or services if applicable. If the visit involved orthopedic procedures (reduction, immobilization, injection, physical therapy), add them to the case. Link them to the affected body area for clarity.

8. Document any treatment plan or orders. Note any medications prescribed, immobilization devices (cast, brace, splint), or physical therapy referrals.

9. Save the case. Click Save or Done. The orthopedic case is now part of the patient's medical record. The body map visually shows where the injury was documented, making it easy for future clinicians to understand the patient's issue at a glance.

Accounting impact

Orthopedic services are billed by service code and procedure. When you document findings on the body map and record procedures or services, the billing system captures those charges. Revenue is recorded against your orthopedic or general medical service income account. If the case is invoiced, each documented service appears as a line item. The body map marking helps ensure the correct services are billed to the correct body area.

Tips & common mistakes

• Be specific about location. Clicking "Right knee" is more useful than just "Knee pain." The body map lets you be precise, so use that advantage.
• Mark all affected areas. If the patient has injuries to multiple joints or body areas (e.g., both knees, plus lower back), mark each one. This creates a complete record and ensures all affected areas are documented and billed.
• Use the body map consistently. Always click the map when a patient has a localized injury. This trains the system to associate findings with anatomy, improving future searches and reporting.
• Document baseline and follow-up findings. If a patient returns for a follow-up visit, you can create a new orthopedic case or add findings to the existing one. Marking the same area over time shows how the injury healed or progressed.
• Link procedures to the body area. If you performed a procedure (injection, manual therapy, cast placement), make sure it's linked to the correct body area on the map.

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