MyEMR for the Pocket PC:  Current subjective complaints

 

The patient's current subjective complaints are immediately displayed when pressing the "S" button on the SOAP note toolbar.

 

• After adding a complaint, everything on the complaint window is optional, but practical to adequately describe a complaint.
• All complaint entries are saved in the patient's file for an at-a-glance review on a subsequent visit.
• Indicate a subjective complaint's area as left, right bilateral or along the midline.
• Indicate the overall severity* of the complaint as mild, moderate, severe, etc.
• Indicate the overall frequency** of the complaint as constant, frequent, occasional or intermittent.
• Indicate the overall status of the complaint as a variety of statuses, including improved, unchanged, worsened, much improved, etc.  Complaint statuses with the ¶ paragraph symbol provide comprehensive inclusion of related sensations, and aggravating/relieving factors (worse/better factors).
• Percentage improved scale
• Numerical pain scale
• Differential diagnosis catalog
• FAST! – the checkered flag button instantly toggles all complaints to an improved status, unchanged status or a worsened status. 
• The up/down arrows allow you to sort subjective complaints such that you can arrange the order of the primary complaints and secondary complaints.
• For patients with a large number of complaints, instantly expand the complaint display to show up to 15 subjective complaints.
• See how to add a new subjective complaint.
• See the patient's ADL's or activities of daily living restrictions.
• Manage the random text generation document window, with the resulting chiropractic SOAP notes, exams and narrative reporting.

 

 

* The overall severity of the complaint is distinguished between the severity of the radicular, or related sensation.  For example, low back pain may be mild, but there may be a severe tingling and throbbing pain radiating through the posterior right leg.

 

** The overall frequency of the complaint is distinguished between the frequency of the radicular, or related frequency.  The low back pain may be constant, however the radicular pain may be occasional.