Completing the Subjective Section of IE

Completing the Subjective Section of the Initial Evaluation

The Subjective section is sub-categorized in the following areas: 

• Reason for treatment
• Prior level of function
• Current level of function
• Functional problems
• Pain assessment
• Patient concerns
• Medical history
• Personal information

This section was built in such a way so that the required elements are minimal. In the paragraphs below we will take a deeper look into each section pointing out the required elements along the way. 

1. Reason for Treatment provides an area to give a high-level overview as to why the patient is being seen for treatment.

*Denotes a required piece of information

• Condition Type*
• Date of Onset*
• Acute/ Sub-Acute/ Chronic
• Prior Treatments*
• Prior Tests*
• Mechanical Stresses & Symptoms
• Mechanical History & Review
• Bladder & Bowel 
• Voice & Speech

**Note: The fields highlighted in RED are required. 

A user must select a  Condition Type for the patient from the choices of Insidious, Injury, Post Surgical, and Other.

• Depending on which type is selected the Corresponding Free Text areas will display underneath. 

Date of Onset may be pulled from the Referral Tab if this information has been entered in during the case setup.

• This date can be entered or changed by clicking on the Date Field.
  • Type the Date of Onset using the keyboard
  • Select a Date of Onset from the Calendar

Updates to the Date of Onset will be communicated back into the Referral Tab and updated accordingly.

Acute, Sub-Acute, or Chronic is an optional multiple choice if they want to report this information. 

• Acute- Pain goes away
• Sub-Acute- Pain comes and goes
• Chronic- Pain is constant and unbearable

Prior Treatments and Prior Tests require that you answer Yes or No.

• If YES, the system will display a list of Prior Treatments/ Prior Tests from which the user may select applicable items. 

• If a choice is missing from the list, you may select Other and type the name in the free text box provided. 
• There are also Prior Treatment Notes and Prior Test Notes sections provided at the bottom of each section as well.

Mechanical Stresses & Symptoms and Mechanical History & Review sections were created to provide the necessary templates for McKenzie Certified clinicians. To open the section click the + icon.

Bladder & Bowel provides an area to collect common subjective information for treating a patient with bladder and bowel issues. To open click the + icon. 

Voice & Speech provides a free text area for any subjectively reported information that would pertain to Speech Language Pathology. To open click the + icon.

2. Prior Level of Function provides an area to report the prior functional limitations of the patient to provide a baseline. This is a required element for the initial evaluation documentation to comply with Medicare guidelines. 

• To enter a Prior Level of Function, a user may either: 
  • Type in the provided Prior Functional Limitation Notes Free Text area 
  • Select from a drop down of commonly used terminology to describe the functional limitation of the patient.
• Selected drop down items will be pulled down into the Prior Functional Limitations Notes Free Text area and may be edited. 

3. Current Level of Function provides an area to report the Current Level of Function for the patient through Self Assessed Function or Scales.

The information entered in this section will be used for  Functional Outcome Reporting to comply with Medicare guidelines. 

By default, a common  Self Assessed Functional Scale will display depending on the Body Region selected in the Initial Evaluation Header. 

• This may be changed by selecting a  Different Scale from the drop down menu.

• Choosing the  Other option in the drop down menu will allow you to name and enter your own.

Complete the  Current Level of Function requirements by: 

• Enter the  Score that the patient reported on the Selected Self Assessed Function Scale.

• The system will auto-calculate the patient's Current % Limitation below based on the Selected Self Assessed Function Scale Equation.

• Enter a  Goal % Limitation for the patient in the field provided.

• Users may add additional scales by Selecting a Scale from the drop down and clicking on the Add Scale button.

• The Additional Function Scale will be added with corresponding Score and Goal % Limitation fields for that patient.

• If you would like to track functional gain for a patient with the  Self Assessed Functional Scale that you have added. You may do so by clicking on the Flag button next to the Scale.

• This flagged scale will be added to the Quantitative Objective Findings Table in the Assessment section to be tracked throughout the duration of care for the patient. 

**Note: Only flagged items will pull to the PDF version of the Initial Plan of Care.

4. Functional Problems provides an area for listing the subjectively reported functional problems of the patient. This is the ONLY portion of the Subjective section that is fully Template Based. 

**Note: At least ONE functional problem is required. (to bypass this type N/A or (-) into the section)

• To add a  Subjective Reported Functional Problem simply type in the available Functional Problem Free Text field. 

• As you type, an additional  Functional Problem Free Text field will populate below. You may add as many problems as you'd like.

• Below is an example of what a  Templated Functional Problems List might look like for a Shoulder Template. If used to to fill out this section you would only need to modify, edit, or delete problems per the current patient's needs. 

• To include  Functional Problems in the Narrative Problems List of the Assessment section, flag the problem by clicking on the Flag icon.

**Note: These items may be edited and have goals assigned to them within the Assessment section. If a template is used, goals may already be assigned requiring only slight modification.

5. Pain Assessment provides an area to communicate the following: 

*Denotes a required piece of information

• Subjective Pain Assessment with Activity*
• Subjective Pain Assessment at Rest* 
• Subjective Pain Assessment Range
• Pain Description
• Pain Location
• Pain Aggravating Factors
• Pain Alleviating Factors
• Create Pain Diagrams

Assign  Subjective Pain Assessment with Activity and Subjective Pain Assessment at Rest by clicking on the appropriate pain value on the 0 to 10 scale.

• Subjective Pain Assessment is measured so that a score of 0 is no pain and a score of 10 is the worst pain imaginable. 

• If you wish to track one of these  Subjective Pain Assessments throughout the duration of care, flag the item by clicking on the Flag icon next to it.

A  Subjective Pain Assessment Range may be assigned by:

• Selecting all that apply in the Pain Description drop down menu.

• You may also assign a Custom Pain Description by:

  • Selecting Custom in the Pain Description drop down menu
  • A Pain Description Free Text area will display for you to fill out

A  Pain Location may be reported by: 

• Typing in the Location Free Text area provided

You may elect to create a  Pain Diagram by: 

• Pressing on the Create Pain Diagram button

A  Pain Diagram pop up will appear on your screen

• Select the Pain Type from the Pain Legend

• Click on the corresponding  Pain Location on the Pain Diagram Image

• To remove/ edit click on the Remove button in the Pain Legend

• Then click on the items you wish to remove in the  Pain Diagram Image

• To add  Additional Pain Notes to the Pain Diagram type in the Additional Pain Notes Free Text area provided

• To save click on the Save button located at the bottom of the Pain Diagram

• You will know that the  Pain Diagram was saved because the Create Pain Diagram button will now show as Edit Pain Diagram

Additional Notes provides an area within the Subjective section to report any additional information that you would like to provide for the patient.

At the bottom of each section you will notice the following area:

In this area you will be able to:

• Save as New Template – save Template Based information as a New Personal Template
• Update Template – update the current Template
• Save Changes – Save the Section quickly if you need to leave the document 
• Next Section – Saves the Current Section and opens up the next section to proceed with filling out the document.

6. Patient Concerns provides an area for users to list a patient's chief complaints or concerns. Patient concerns are NOT Required to be filled out.

• To add a concern simply type in the provided  Patient Concern Free Text area. As the Patient Concern Free Text area is completed an additional Patient Concern Free Text area will populate below for any additional concerns. 

• If a concern should be added to the  Narrative Problems List for the Assessment section, a user may choose to Flag the concern.

  • Flagging the item will pull the typed text into the Narrative Problems List for the patient.

7. Medical History provides an area to fill out: 

*Denotes a required piece of information

• Medications*
• Past Surgery*
• Comorbidities/ Precautions*
• Fall History
• Drug History
• Additional Medical History Notes

Enter and fill out the required information for  Medications by: 

• Answer  Yes or No

  • If Yes is selected, either fill out the Medications Free Text area or check the See Medication List checkbox
  • If No is selected, nothing will display to be filled out

Enter and fill out the required information for  Past Surgery by:

• Answer  Yes or No

  • If Yes is selected, either fill out the Past Surgery Free Text area or check the See Surgery List checkbox
  • If No is selected, nothing will display to be filled out

Enter and fill out the required information for  Comorbidities/ Precautions by:

• Selecting  None or at least one comorbidity or precaution from the list: 

To include a  Comorbidities/ Precaution on future documentation select the Checkmark icon next to it. This will be included in the header of future Daily Notes and Progress Notes. 

Include  Fall History and Drug History by pressing on the + icon on the section.

Enter any other  Additional Medical History Notes in the optional free text area provided. 

8. Personal Information provides an area to fill out:

**Note: Nothing is required in this section. It's completely optional. 

• Occupation
• Job Duties
• General Activity
• Hobby/ Interest
• Work Status & Restrictions
• Living Situation
• Dietary Considerations
• Learning Styles & Readiness
• Psychosocial Considerations
• Cognition & Mentation

As you may have noticed, a few commonly reported items such as  Occupation, Job Duties, General Activity, and Hobby/ Interests will display by default for easy entry. 

• To provide Other Personal Information you can do so by pressing the + icon in that section. Please see example below with Work Status & Restrictions.
• The corresponding Work Status & Restrictions section will open providing additional fields to enter information.