Chief Complaints template captures patient problems and creates CMS compliant description. Enabledoc contains a SNOMED CT coded problem list. The selected field dynamically builds sentences in the note to describe the problem(s). Simply click on Word Processor under the main menu to see the resulting sentences that are created.
The Chief Complaints screen contains the following tabs:
Problems
The Problems tab displays the list of chief complaints or problems added for the current encounter. Information such as Problem Description, SNOMED Code, Status, Resolved status, End Date, Health Concern, and Health Risk is displayed. Users can also edit or delete existing problem entries from this screen.
Problem Description: Displays the documented patient problem or complaint.
SNOMED Code: Displays the SNOMED CT code associated with the problem.
Status: Displays the current status of the problem.
Resolved: Indicates whether the problem has been resolved.
End Date: Displays the end date associated with the problem, if applicable.
Health Concern: Indicates whether the problem is marked as a health concern.
Health Risk: Indicates whether the problem is marked as a health risk.
Edit: Allows modification of the selected problem entry.
Delete: Removes the selected problem from the list.
Add New Problem
The Add New Problem tab is used to document a new patient complaint or problem for the current encounter. The screen allows users to search, select, and describe patient problems along with associated clinical details.
Search/Select Problems: Used to search and select problems from the available problem list. Problems can be searched using options such as All Problems, Favorites, Past Problems, and Patient Past Problems. Select the appropriate radio button based on the criteria you wish to use for finding the problem.
All Problems: Displays all available problems from the system database.
Favorites: Displays provider favorite problems for quick selection.
Past Problems: Displays previously used problems.
Patient Past Problems: Displays problems previously documented for the patient.
Add To Favorites: Adds the selected problem to the Favorites list.
Remove From Favorites: Removes the selected problem from the Favorites list.
Education: Clicking this link will open a pop-up window to a site called MedalinePlus®Connect. This webpage will provide more information.
Save Chief Complaints Set: Saves the configured chief complaint set.
Save / Update: Saves or updates the entered chief complaint information.
Cancel: Clears all the fields.
Problem: Used to enter or modify the patient complaint/problem.
This is chronic recurring problem: Marks the problem as chronic or recurring.
Where is the problem located: Used to document the anatomical location of the problem.
What side is the problem on: Used to document the affected side.
What is the Onset of the problem: Used to document how the problem started.
How long did problem last: Used to document the duration of the problem.
How does the problem feel: Used to document the quality or characteristics of the problem.
What is the Context of this problem: Used to document contextual details related to the problem.
How severe is the problem(1 is lowest and 10 is highest): Used to document the severity level of the problem.
If you are returning, is the problem improving or getting worse: Used to document the current progress of a returning problem.
By what percent is the problem improving or getting worse: Used to document percentage-based improvement or worsening.
When did it start: Used to document the onset date of the problem.
If this has occurred before please select an approximate date when it happened: Used to document previous occurrence information.
How often has it occurred: Used to document occurrence frequency.
Enter or select associated Problem: Used to add associated problems related to the complaint.
Denies Symptoms Of: Used to document denied symptoms related to the complaint.
Remarks: Additional comments or notes related to the problem can be entered.
What relieves the problem: Used to document relieving factors.
What aggravates the problem: Used to document aggravating factors.
Is the problem Resolved: Indicates whether the problem has been resolved.
SNOMED: Displays SNOMED-related clinical classification options for the selected problem.
Problem History
The Problem History tab displays previously documented patient problems and encounter history. Users can review historical problem information and add selected problems to today’s encounter.
Select Checkbox: Used to select one or more problems from the history list.
Encounter Date: Displays the date of the encounter in which the problem was documented.
Problem Description: Displays the documented patient problem or complaint.
SNOMED Code: Displays the SNOMED CT code associated with the problem.
Condition: Displays the condition information associated with the problem.
Status: Displays the current status of the problem.
Add To Todays Problems: Adds the selected historical problems to the current encounter’s problem list.
Generated Text
The Generated Text tab displays the clinical narrative automatically created from the documented chief complaint details. Users can review and edit the generated text before saving it to the clinical note.
Save Text To Show In Note: Saves the generated text so it can appear in the patient’s clinical note or documentation.
Other Useful Functionalities:
- Pull Forward For Next Visit: Copies today's chief complaints into the next visit note so the provider doesn't have to retype them.
- Lock: Locks the recorded chief complaints for today's visit so they cannot be altered.
- Post To Care Dashboard: Adds today's chief complaints to the patient's main profile screen so anyone opening the chart instantly sees what the patient is being treated for.