Document a Chief Complaint and History of Present Illness

To add chief complaints and associated history of present illness information:

1 Click CC & HPI on the left-hand side of the page.

2 In the first available Chief Complaint box, type a statement that describes the symptom, problem, or condition that is the reason for the patient encounter.

3 If you want to document the history of the present illness for the chief complaint, click and select the appropriate form from the Select HPI Form list.

4 Repeat steps 2-3 to add additional chief complaints and associated forms for the history of present illnesses.

To add additional chief complaints and a history of the patient’s present illness, click . To remove a chief complaint and the corresponding history of present illness, click .

5 Do one of the following:

• Click Save and Close if you do not want to document the history of the present illness at this time.

• Click Enter HPI if you want to proceed with documenting the history of the present illness. Continue with step 6.

6 On the Enter HPI dialog box, click the tab for the chief complaint/history of present illness that you want to document.

7 Click each category to expand it and view related symptoms, problems, behaviors, or conditions. Do any of the following:

• To indicate a patient’s status for each particular item:

• Click the Yes or No option button or select the check box next to each item, as appropriate, and then optionally type information in the text boxes that appear.

• Click green, underlined items to view sub-items relevant to the symptom, problem, behavior, or condition. Select the appropriate check boxes and then optionally type information in the text boxes that appear.

• To identify a symptom, problem, behavior, or condition that is not included in the list (add a new line item), type it in the Other box, and click Add.

• To add additional information for a history or present illness, type text in the Additional Comments box.

Additional comments can be added without selecting any of the available options.

8 To add one or more categories to the history of present illness form, click Add Systems at the top of the Enter HPI dialog box. Select the category or categories that you want to add to the history of present illness for this form.

9 If you have added multiple chief complaints (with associated history of present illness forms), repeat steps 6-8.

10 Do one of the following:

• Click Save to save the information you have entered and close the dialog box.

• Click Edit CC to add another chief complaint and corresponding HPI form or to change the HPI form associated with a chief complaint.

To make changes to the patient’s chief complaint(s) and history of present illnesses:

1 Click Edit CC in the body of the encounter note.

2 Modify each chief complaint, as needed.

3 If you want to change the history of present illness form associated with a chief complaint, click and select the appropriate form from the Select HPI Form list. When the Confirm Form Switch dialog box appears, click OK to confirm the change.

4 If you need to add additional chief complaints and history of present illness forms, click , type the chief complaint, and then click the appropriate form in the Select HPI Form list.

5 If you want to remove a chief complaint and its associated history of present illness form, click .

6 Do one of the following:

• If you are finished making changes, click Save.

• If you want to make changes to the history of present illness forms, click Enter HPI and then continue with step 2 of To make changes to a patient’s history of present illness:.

To make changes to a patient’s history of present illness:

1 Click the CC & HPI area of the encounter note.

2 Click the tab for the history of present illness that you want to update.

3 Click a category to expand it and then click green, underlined items to view sub-items relevant to the symptom, problem, behavior, or condition.

4 To change a selection or add information for an item, select different options for each item or type text in the text boxes.

5 To remove a yes or no selection for an option and any notes that have been entered, click the Clear link to the right of the item you want to remove.

6 When you are finished editing the history of present illness information, click Save.