Symptoms and Impairments

Record Symptoms and Impairments, by default, in an Intake Note, Progress Note Optional sections, In/Outpatient Treatment Plan, and in a Discharge Note. You can also set it up to appear in any note or report.

Symptoms/Impairments consists of five sub-sections:

Note: The symptoms pick list is based on the diagnosis or diagnoses you entered for the client. If you have not entered a diagnosis, the pick list will be empty.

 Click the buttons at the top of the window to enter associated impairments.

To Add a Symptom or Impairment

To enter a symptom or impairment from the pick list, double click it, or drag and drop the item to the list box below.

A pop-up box for the Symptom or Impairment will display the item you selected. Select a severity rating by clicking on an option. Click OK. The item and the accompanying severity rating appear in the list box. You can enter any number of Symptoms or Impairments.

Impairments: All Social, Work, School, and Self Care impairments that you enter are listed together in the Current Impairments list box.

To enter your own symptom or impairment (one not on the list), click the blue underlined text Add...Enter an item and associated severity level in the pop-up box. Items entered this way will not be added to the pick lists.

To Edit the Impairments Pick List

If you have access rights, click the pick list icon in the upper right of the window to edit the list of social, work, school, and self-care impairments.

Note: The pick list icon does not appear for Symptoms. The Symptoms list is drawn from the DSM-IV and cannot be edited.

Edit

Double-click item to edit, or click to select the item in the lower list box, and then click the blue underlined text Edit Selected.... Make changes in the dialog box, and click OK.

Delete

In the lower list box, click on the item to select it and press the Delete key, or drag and drop into the trashcan.

Graph Symptoms and Impairments

The Patient Summary Graph will graph the symptoms and impairments you record for each client.

See Also

Documentation Setup

Generate Print Notes