EMR User Manual
Subjective
To Create Subjective Complaint(s)
- This area allows users to add one or more complaints to a patient's note.
- Users may either enter the complaint(s) manually by checking "Enter Complaint Manually", or you may build your complaint using the pre-existing drop-down menus. (Note: If you choose to enter the complaint manually, the only drop-down menu that will remain available to utilize for that complaint is the "Severity" drop-down.
- The Aggravated/Relieving Factors have pre-defined items within the drop-down menu but users also have the ability to add their own factors to the drop-down menu by clicking in the menu typing the data, then clicking enter. You will receive a pop-up that reads data saved successfully and once you click in the drop-down field you will see it in your list. It will also include an ''x'' next to it allowing you to delete it from your list overall. This can be done on any drop-down menu with the "+" to the right.
- Once you save your complaint at the bottom of the screen, the system will drop it into the table at the bottom.
- Updating Pain Severity from the drop-down in the table Auto-Saves, you do not need to pull the entire complaint up to update pain severity
To Edit or Remove Subjective Complaint
- Click on the complaint within the table and the system will load the complaint details to edit back into the top of the page.
- Click on the complaint within the table and click the 'Clear' button at the bottom of the page.
When utilizing the Patient Online Intakes, the patient's subjective complaints will auto-populate into the table at the bottom.
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