Identifying Information is, by default, found in the Intake Note and in the Outpatient Treatment Plan. You can also set it up to appear in any note or report. It consists of three sub-sections.
| • | Identifying Information |
| • | Presenting Problems |
| • | Stressors |
Click the buttons at the top of the window to access the corresponding sub-sections.
Identifying Information
Living Situation
Enter a statement describing the client's living situation. Complete the sentence stem, "The patient is currently..." (e.g., living with his wife and three children).
Employment
Use the drop-down list to select employment or school status, or enter your own statement (e.g., enrolled in the 9th grade). For list items followed by an underline (e.g., self-employed as _____), complete the stem in the input dialog box and choose OK. Choose Cancel to exit. The item will not be inserted into the field.
History provided by...
Enter the person who provided the history (e.g., the client or a parent).
Chief Complaint
Use the text box to enter the chief complaint and/or history. The latter is an ideal area to use voice recognition software. Select Spell Check from the File menu while your cursor is in the text box to check your spelling.
Presenting Problems and Stressors
Click the tab button in the Identifying Info section of the Intake to open the Presenting Problems window.
Click the tab button in the Identifying Info section of the Intake to open the Stressors window. Double click an item to select it, or drag and drop the item from the problem or stressor pick list to the ...at Intake list box below. A pop-up window for entering details for the Presenting Problem or Stressor will display the item you selected.
Problems: Click on a severity or frequency rating in the list that most describes the problem, and specify the duration of the problem by typing it in the field (e.g., six months).
Stressors: specify the date of onset or the duration of the stressor ( e.g., six months).
Click OK. The problem or stressor and the accompanying information appears in the list box. You can enter any number of problems or stressors.
Entering your own Problem or Stressor
To enter your own problem or stressor (one not on the list), click the blue underlined text Add.... Enter a problem or stressor and/or associated information in the pop-up window.
To Edit a Problem or Stressor
| • | Double-click item to edit or click to select the item and click Edit.... |
| • | Make changes in the dialog box, and click OK. |
To Delete a Problem or Stressor
In the list box, click on the problem or stressor to select it, and press the Delete key. Or, Drag and Drop into the trashcan in the lower right of the screen.
To Edit Pick List
If you have access rights, click 
to edit the problems or stressors pick list.
See Also