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

Version 20.10

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:

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

Adding Additional Complaints

The steps below are used when adding an additional CC/HPI form when a template is not selected from the All Templates or Author Specific lists.

  1. Click the + Add CC/HPI button. A blank form is displayed.
  2. Type a complaint into the CC field and select from the drop-downs or type in the text field of HPI. 

NoteTo view additional CC/HPI information, click the right-facing or left-facing arrow. To remove an added CC/HPI, click the Delete button after confirming you are on the correct form.

Click here to see a video representation of how to layer a Symptom template and move through the the CC/HPIs that have been added to the Encounter.

Document Review of System (ROS)

The ROS section is 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 20.8

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.