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Encounter: Document Chief Complaint, History of Present Illness, and Review of Systems

Version 20.7

Overview

The CC/HPI/ROS section of the Encounter Note is divided into three sections to document the Chief Complaint (CC), History of Present Illness (HPI), and Review of Systems (ROS). 

Pediatric practices differ on who is responsible for documenting these sections of the CC/HPI/ROS. As always, follow your practice's policy for entering this information.

Document Chief Complaint (CC)

The CC field is a text box where:

  • The field is populated with the chief complaint from the template applied.
  • You may click into the text box and type additional information.
  • You may use the Phrase Construction button and select phrases to insert.

Document History of Present Illness (HPI)

The HPI is a combination of elements with drop-down menus and a text field. The elements of the HPI include:

  • Fever
  • Location
  • Timing/onset
  • Duration/pattern
  • Severity
  • Quality
  1. Click in to the drop-down for each pertinent element and select from the list.
  2. Click in to the text field:
  • Type in the answer to any question/statement populated from the template applied.
  • Click in to the text field and type additional information.

Document Review of System (ROS)

This is the section where you can assess and document the patient's symptoms categorized by body systems.

  1. To change the symptoms of the ROS click on the word in the Rpt/Deny column.
  • Click Pert once to change to Reports and click again to change to Denies. If the symptom is not applicable, and you do not want it in today's note, simply leave the items as Pert.

NoteAny symptoms left as pertinent (Pert) will not be seen on the final note. If a symptom is marked as Reports or Denies, and should not appear on the note, click through until you see Skip.

  1. To add additional comments or notes to an ROS line, click in the comment field and enter your comment. Phrase Construction can also be used by clicking the Phrase Construction button  located in the Comment field.

Version 14.10

Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS)

This section will introduce the users to the section of the Encounter note used to document the chief complaint, history of present illness and the review of systems.  The user will be guided through the fields to easily review and document additional information.

Note:  A note in Office Practicum is divided into sections similar to the SOAP (Subjective, Objective, Assessment, Plan) note. The subjective part of the exam includes sections such as Chief Complaint, History of Present Illness, and Review of Systems. Each practice determines how much of the subjective portion of the visit a clinical person (Nurse, MA) finishes. The Objective part of the exam includes sections such as vitals and the exam itself.

Click on the CC/HPI/ROS tab

  • This window is divided into three sections Chief Complaint (CC), History of ´╗┐Present Illness (HPI), and Review of Systems (ROS).
  • Encounter Note: CC/HPI/ROS tab

    Documenting Chief Complaint (CC)

    Encounter Note: CC/HPI/ROS tab: CC section

    The CC field is a text box where you can type in the reason for the visit or select the Phrase Construction button and select phrases to insert.

    History of Present Illness (HPI)

    Encounter Note: CC/HPI/ROS tab: HPI section

    In the HPI field you can Select (drop down fields) and/or Type (text box) in the History of the Present Illness. 

    1. Dropdown Fields: Information can include data such as timing of onset of symptoms, duration, severity, location (i.e. left ear), and did they have a fever before coming in to the office.

    • Select from one of the choices in the dropdown menu.
    • If the choice you want is not in the dropdown menu, then, simply Type in the desired information.
  • The dropdown lists include:

    SelectionDescription
    Fever dropdown list
    Location dropdown list
    Timing/onset dropdown list
    Duration/pattern dropdown list
    Severity dropdown list
    Quality dropdown list
    1. Text Box: where you can Type in additional information that is not part of the dropdown section.
  • Note:  If there is pre-filled information, as part of a template and the information is not applicable simply delete it and type in the relevant information.

    Review of System (ROS)

    Note:  Please check with your supervisor to see if you will be documenting the Review of Systems as a clinical staff member. Pediatric practices differ on who documents the ROS.


    Note:  This is the section where you can assess and document the patient's symptoms categorized by body systems. Systems in Office Practicum: Constitutional, Eyes, Ear Nose Throat, Respiratory, Cardiovascular, Gastrointestinal, Genitourinary (M/F), Musculoskeletal, Integumentary (Skin/Breast), Hematologic/Lymphatic/Immunologic, Endocrinology, Neurologic, Psychiatric, Allergic/Immunologic.

    Under each System, various symptoms are listed which you can mark as 'Reports' 'Denies' or leave as 'Pertinent'.  Anything marked 'Reports' or 'Denies' will be part of the final note. Anything left as 'Pert' (pertinent) will not be part of the final note.

    More systems and symptoms can be added to this list as applicable per visit.


    To change Symptoms to be Reports or Denies

    • If the symptom is not applicable and you do not want to write it in today's note, simply leave the items as 'Pert'. Any symptoms left as pertinent will not be seen on the final note.
  • Click on the word itself. Click Pert once to change to Reports and Click again to change to Denies.

    • If you already marked it as 'Reports' or 'Denies', and then decide you do not want it in your note and want to skip it, simply, click through until you see Skip.
  • For example, if I wanted to change 'sore throat' from 'Pert' to 'Reports', I will click on the word "pert." I can also, write in any further explanation in the 'Comment' section.

    Encounter Note: CC/HPI/ROS tab: ROS section