The Subjective Complaints is where the patient’s Subjective Complaints are entered and monitored on each visit. The first time this window is accessed for a patient, prior to making any entries, the Complaints box is empty and nothing is highlighted on the body view.
Depending on the Subjective Complaint of the patient, it may be necessary to change the view of the body. Entering a Subjective Complaint for the patient is quick and easy. Point the mouse at the part of the body in which the patient has his/her complaint. Click on that body area and a list of possible problems appears.
Updating Complaints is simple. Once the patient’s Subjective Complaint window is open, existing complaints are listed in the central Complaints column. Simply click on the Complaint to open its window, make the appropriate changes, and click on the green check at the top of the window.
The Subjective Complaints window includes several special functions. These functions can speed the processing of a patient without compromising the accuracy of the SOAP note documentation.
In the upper right corner of the Subjective Complaints screen is an area for Patient Comments. Anything determined to be important can be entered in Patient Comments and it will be added to the Subjective area of the final SOAP note. It is critically important to enter anything the patient states on each visit in order to comply with State Board and Federal regulations that require uniqueness in every SOAP note for each and every visit.