When a patient reports a new or previously unrecorded complaint or symptom, it's essential to document it as a complaint in the encounter. This ensures accurate documentation within your SOAP notes.
Click below to find out more about managing complaints:
How are complaints created?
Complaints can be created both automatically and manually.
- Complaints are automatically generated when a patient completes the Chief Complaint Survey (CCS).
- At the conclusion of every CCS, patients are prompted with the question, 'Do you have any other symptoms to report?' If they click 'Yes' and report additional symptoms, a second complaint is created within the encounter.
- If a patient did not already report their complaint via the CCS, you can manually add a complaint to the encounter.
Complaints carry over to subsequent encounters (visits) until the complaint is deactivated or deleted.
Add a complaint to an encounter
You should only manually add a complaint if the complaint has not already been reported via the CCS.
In the event that you need to manually add an additional complaint, click the + icon next to the green Manage Complaint button.
Then, you'll receive a prompt to send the CCS to the patient via email or text, or you can complete the survey directly on your screen using the My Screen option.
Upon completing the survey, a new complaint will be added to the encounter! Like all complaints, this complaint will carry over to subsequent encounters until it is deactivated.
Resolve/deactivate, skip, pause, or delete a complaint
Click the Manage Complaints button to resolve/deactivate, skip, pause, or delete a complaint.
- Skipping a complaint will ‘skip’ documentation for the current encounter. The complaint will be active again on the patient's next encounter. Use this option if you need to skip documentation for just one visit.
- Resolving/deactivating a complaint will add documentation to your SOAP Note noting the conclusion of treatment. The complaint will not carry over into the next encounter if it has been resolved/deactivated.
- Pausing a complaint will pause documentation for all future encounters until the complaint is 'un-paused.' Use this option if you need to pause documentation for more than one visit.
- Deleting a complaint will remove the complaint entirely from the current encounter. Use this option if the complaint was added in error.
Designate PRN status
When using the SOAP Wizard, you can choose to assign a complaint with PRN status. Complaints labeled as PRN won't trigger a care plan, meaning no interim or re-exam surveys will be sent to the patient for future visits related to that PRN complaint.
1) Navigate to the encounter and then access the Assessment Wizard for the complaint you wish to designate as PRN.
2) Toggle ON the PRN switch.
