- Go to the Advanced Progress Note screen.
- Press the Chief Complaint button, located in the Side Bar section.
- Or, click on the Search button located at the top of the screen and select the Chief Complaint option.
- The user can also access through the Clinical Evaluation section by clicking on the Chief Complaint text.
- The following screen will be displayed:
- Or, click on the Add button in the Clinical Evaluation section.
- The following screen will be displayed:
The user has three options for saving information on this screen.
Through a selection of articles
- Go to the Advanced Progress Note screen.
- Select all applicable items for clinical evaluation.
- Once selected, press the Save button to save them.
- They will automatically be displayed in the Clinical Evaluation section.
Through Load Last
- Go to the Advanced Progress Note screen.
- Go to the Chief Complaint section, through any of the sections.
- Press the Load Last button.
- The following confirmation message will be displayed:
- Press the Yes button to add the options of the last patient encounter.
- Press the No button to cancel the action.
- Pressing Yes will automatically display the options of the patient's last clinical evaluation.
- Press the Save button to save the evaluation.
- Automatically, the selected options will be displayed..
Through Templates.
- Go to the Advanced Progress Note screen.
- Go to the Chief Complaint section through any of the sections.
- Press the Select Template button, located at the top of the screen.
- The following screen will be displayed:
- If you wish to add an item to the screen, press the right mouse button and select the Add Item option.
- The following screen will be displayed:
- Enter the necessary information and then press the Save button.
- Once you have completed the clinical evaluation of the patient, press the Save button located at the top of the screen.
- If you want the information to be displayed in syntax form, you must select the Use enhanced syntax option in the Settings section before starting the patient assessment.
- The saved information will be displayed in the Advanced Progress Note screen in the Clinical Evaluation section.
- The provider will also be able to document, from the Clinical Evaluation section.
- By typing under the Chief Complaint text.
- Once you have finished documenting the information in the section, press the Enter button on your keyboard.
Through Smart Box
- Go to the Advanced Progress Note screen.
- Click on the Smart Box tab, located on the right side of the screen.
- The following section will be displayed:
- Select a phrase, then drag it to the Clinical Evaluation section.
- Automatically, the phrase will be displayed in the section of your choice.