By default, the Main tab (figure 3) is the first section to appear when the window is opened. It is the master tab for the Complaint.
Left, Bilateral and Right
Under the Main tab, due to legal mandates of State Boards and Federal agencies, it is required that the Complaint location (Left, Bilateral, or Right) must be identified. Click on the appropriate button.
Severity
A description of the Complaint must also be present in the documentation. Click on the down arrow on the right side of the Severity box and select the choice that is appropriate for the patient by pointing at it with the mouse and clicking on it. The drop down box will close and the selection will fill in the box.
Frequency
Next identify the Frequency of the patient’s complaint in the Frequency box. Make the selection by clicking the drop down arrow and choose the one that matches what the patient reported.
Status
The third selection is the Status of this Complaint. From the Status box choose the item that matches what the patient has noted. It is important to recognize that the items with a paragraph symbol (¶) include all the information entered about this complaint in the SOAP note; the items with no paragraph symbol produce only a single simple sentence.
Pain Scale and % Improved
Below these 3 boxes there are 2 sliding scales, one for Pain Scale and the other for % (percent) Improved. The Pain Scale is based on 0 = no pain to 10 = the worst pain imaginable. It should be used not only on the patient’s first visit, but on every visit on which there should be a record of how the patient perceives that he/she is progressing. The % Improved scale can be used only on the second visit and thereafter.
The Pain Scale on this screen is specific to the individual complaint. If the patient has 2 or more complaints, each may and should have its own rating. The Oswestry Visual Analog Scale described in another chapter is for the patient to evaluate his/her overall condition and is not specific to individual complaints. Note that the Visual Analog Scale is recognized only as a Subjective item by Medicare. To qualify as an Objective Finding for Medicare, there must be proof that the patient completed any Functional Outcome Assessment form that the practice uses. At this time, it means that the form must be signed by the patient.
There are 2 methods of recording entries on these sliding scales. Method 1 is to point the mouse at the place on the scale where the scale pointer should be, and just keep clicking at that point until the scale pointer moves to that spot. Method 2 is to point the mouse at the little pointer on the slider bar; click and hold the left mouse button down while you drag the pointer to the location for the finding.
Pain Quality¶
The Pain Quality¶ box provides a checklist of the various qualities of pain that the patient may describe. Check off as many as the patient uses to have an accurate record.
Sensation¶
In addition to the Pain Quality, many patients also describe altered Sensations in the affected area that are part of the Complaint. The Sensation¶ box provides a checklist of the various types of Sensation that the patient may describe. Check off as many as the patient uses to have an accurate record.