When a patient reports a new or previously unrecorded complaint or symptom, it's essential to document it as a complaint in the encounter. This ensures accurate documentation within your SOAP notes.
Click below to find out more about managing complaints:
How are complaints created?
Complaints can be created both automatically and manually.
- Complaints are automatically generated when a patient completes the Chief Complaint Survey (CCS).
- At the conclusion of every CCS, patients are prompted with the question, 'Do you have any other symptoms to report?' If they click 'Yes' and report additional symptoms, a second complaint is created within the encounter.
- If a patient did not already report their complaint via the CCS, you can manually add a complaint to the encounter.
Complaints carry over to subsequent encounters (visits) until the complaint is deactivated.
Where do I view active and inactive complaints?
In the patient's encounter, existing complaints are displayed in the SOAP note panel, identified by the region of pain (e.g., shoulder, lower back, ankle, etc.).
For example, the below patient has 2 active complaints— a shoulder complaint and a lower back complaint.
You can also view all active and inactive complaints from the patient's dashboard.
Manually add a complaint to an encounter
You should only manually add a complaint if the complaint has not already been reported via the CCS.
In the event that you need to manually add an additional complaint, click the + icon.
Then, you'll receive a prompt to send the CCS to the patient via email or text, or you can complete the survey directly on your screen using the My Screen option.
Upon completing the survey, a new complaint will be added to the encounter! Like all complaints, this complaint will carry over to subsequent encounters until it is deactivated.
Deactivate a complaint
When a complaint has been resolved, released, or referred for alternate care, you’ll want to deactivate the complaint within the encounter.
1) Navigate to the encounter and click on the complaint you would like to deactivate.
2) Click Deactivate Complaint in the top right corner of the subjective preview.
3) Select the deactivation reason before confirming the deactivation of the complaint.
After successfully deactivating a complaint, you will see the red Deactivated message for that complaint.
Note: you can only deactivate complaints from an unsigned SOAP note.
Skip a complaint
If you do not yet want to deactivate a complaint, but you do not want to document it in your SOAP Note, you can skip the complaint.
1) Navigate to the encounter and click on the complaint you would like to skip.
2) Click Skip Complaint in the top right corner of the Subjective preview.
After successfully skipping a complaint, it will be marked with a skip icon. You can then continue on completing the remaining sections of your SOAP note.
Note: you can only skip a complaint if the patient has more than one active complaint.
Designate PRN status
When using the SOAP Wizard, you can choose to assign a complaint with PRN status. Complaints labeled as PRN won't trigger a care plan, meaning no interim or re-exam surveys will be sent to the patient for future visits related to that PRN complaint.
1) Navigate to the encounter and then access the Assessment Wizard for the complaint you wish to designate as PRN.
2) Toggle ON the PRN switch.
