Overview
Healthcare professionals can now enhance their documentation by including a pain level in the Subjective sections of Progress Notes and Discharge Documents. This feature allows for more precise recording of a patient's pain, facilitating better treatment and follow-up care. This article will guide you through the steps to add a Pain section to these documents, as well as how to copy a note from the Check in screen.
Steps to Add a Pain Section
1. Create the Document
Begin by creating a new Progress Note or Discharge Document in the electronic medical record (EMR) system.
2. Navigate to the Subjective Section
Once the document is created, navigate to the Subjective section. This section typically includes patient-reported symptoms and experiences.
3. Locate the Pain Section
Within the Subjective section, locate the newly added Pain section. This section is specifically designed to record the patient's pain level.
4. Select the Pain Level
In the Pain section, you will find a drop-down menu. Click on this menu to reveal the pain level options.
5. Choose the Pain Level Number
Select the appropriate pain level number from the drop-down menu. Pain levels are usually rated on a scale from 0 to 10, with 0 indicating no pain and 10 indicating the worst possible pain.
6. Complete the Documentation
After selecting the pain level, continue filling out the rest of the Subjective section and complete the documentation as usual. Additionally, you can utilize the ability to copy from the previous Daily Note at Check-In. This feature pulls the most recent approved daily note or addendum into the current note, ensuring continuity and consistency in patient care documentation.
By following these steps, healthcare professionals can ensure a more comprehensive and accurate record of a patient's condition, leading to improved patient care and outcomes.