EMR > Charting > How to fill out Chief Complaint?

The Charting screen comprises to two main sections, on the left are pre built content headings
(SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN etc). Under these headings, different Level-1 (component)s are listed. When a Level-1 (component) is clicked, a customizable list of items to be included in the chart note is presented on right called Level-2 (Item). The Chief Complaint here includes a few common visit reasons at the top followed by an alphabetical listing of items.

chief_complaint_steps

The items list under Chief Complaint can be oriented any way you like. To add an item to the note simply click in the box next to the item. When a box is clicked, additional items appear on the bottom or on the right for inclusion in your chart note.

Now let us go ahead and enter the Chief Complaint for a patient. The patient was referred from school due to an asthma attack and cough. To enter the Chief Complaint for the above scenario:

	Click on Chief Complaint listed under SUBJECTIVE on the left side on the chart. A list of items will appear on the right, the item list here includes a few common visit reasons at the top followed by an alphabetical listing of visit reasons.
	Since this patient has been referred from school, click in the check box. Choosing this option will bring up additional items below to describe the Chief Complaint. (Here you also have the option to place the cursor next to Referred from school for, click and write your own description if required.)
	Click in the check box as this patient has been referred from school for asthma attack. This will add the description "asthma attack" automatically next to Referred from school for.
	Click in the check box to add this item also to the Chief Complaint. A description "cough" will automatically be added next to the item Referred from school for.

An important point to always remember about charting with PracticeSuite.com is that you may type, handwrite, dictate, point and click or let your transcriptionist do the work. In fact any combination works just as well.

You can also enter other details by selecting the required heading and choosing the corresponding items in the same manner as described above.

5. To make this chart available to the physician for examination, click in the Save as options box and choose then click the Save As button.

6. The Charting Saved Successfully message will be displayed, click the Close button. The chart will be saved and placed under the Ready for exam tab on the Clinical Desktop.

7. Click the Close button to close the charting screen and go back to the Clinical Desktop page and move on to the next patient.