Adding and Editing Patient Complaints

When it comes to documenting the chief complaintClosed The main reason for the patient’s visit to the doctor., you have the option of documenting the complaint as free-form text that more closely resembles the patient's own words or as structured data, guided by check boxes and drop-down menus. How you chose to document complaints—free form or structured—depends on your preference and the needs of your practice.

This page explains how to record a patient’s chief complaint and any secondary complaints as well as how to edit the CC/HPIClosed History of Present Illness. A detailed account of a patient's current health issue, including when it started and how it has changed over time. statement. What do you want to do?

  1. Open a patient visit. To learn how, go to Creating or Opening a Visit
  2. Click the CC/HPI/ROS action bar button or locate the CC/HPI|ROS card in the Visit Overview.

The "other complaint" option enables you to add free-form complaints.

  1. Open the chief complaint. To learn how, go to Navigate to the chief complaint.
  2. Click Add a New Chief Complaint.
  3. Select Other located at the bottom of the list along the left side of the page.

    To get here even faster, locate the CC/HPI|ROS card in the Visit Overview, click the Add CC/HPI or ROS hyperlink and select Other Complaint.

  4. Enter a Condition and Description.
  5. Select HPI Components as needed.
  6. Click Save.
  1. Open the chief complaint. To learn how, go to Navigate to the chief complaint.
  2. Click Add a New Chief Complaint.

    A Search window opens. The 25 most common complaints are displayed at the left of the screen.

  3. Select the patient's chief complaint from one of the 25 most common complaints or search for the chief complaint in the search box.

    The Eye Diagrams appear.

  4. At the top of the screen, click the Eye Diagram view you want to use to record the location of the chief complaint.
  5. Click the eye images to indicate the location of the problem.

    The small box is the legend. Use the red + and - buttons to zoom in and out. Use the blue circle to remove the last dot you entered on the Eye Diagram.

  6. Click Continue.

    The Complaint Details screen appears.

    The questions on the screen allow you to describe the qualities, severity, and duration of the chief complaint. Questions with an asterisk are required.

  7. At the bottom on the screen, select whether is this a new presentation or a follow-up to the complaint.
  8. Click Save.
  1. Open the chief complaint. To learn how, go to Navigate to the chief complaint.
  2. Click Add a New Secondary Complaint.
  3. The Complaint Details screen appears.
  4. The questions on the screen allow you to describe the qualities, severity, and duration of the chief complaint. The questions with an asterisk are required.
  5. Click Save.
  1. Open the chief complaint. To learn how, go to Navigate to the chief complaint.
  2. Click Override for the chief complaint you want to edit.

    The Edit CC/HPI window opens.

  3. Enter your changes.
  4. In HPI Components:
    • Select the items you want to appear in the chief complaint.
    • De-select the items you do not want to appear in the chief complaint.

    Ensure that the paragraph of the chief complaint correlates to the selected HPI components.

  5. Click Save.
  1. Open the chief complaint. To learn how, go to Navigate to the chief complaint.
  2. Click Modify for the chief complaint you want to edit.

    The Eye Images appear.

    The Modify link may be grayed out if you previously click the adjacent Override link and edited information there. If the Modify link is grayed out, you'll have to delete the complaint and add it again.

  3. Click Continue.

    The Complaint Details screen appears.

    The questions on the screen allow you to edit the qualities, severity, and duration of the chief complaint. The questions with an asterisk are required.

  4. Click Save.
  1. Open the chief complaint. To learn how, go to Navigate to the chief complaint.
  2. Click Remove.

    A verification message appears.

  3. Click OK.

If the patient has more than one chief complaint, you can reorder the complaints. This automatically reorders the patient's HPI.

  1. Open the chief complaint. To learn how, go to Navigate to the chief complaint.
  2. If more than one complaint is documented, click Reorder.

    The Reorder Chief Complaints window opens.

  3. Click and drag the complaints to the desired order.
  4. Click Save.