Patient Encounter: CC/HPI/ROS

Version 20.10

About Patient Encounter: CC/HPI/ROS Tab

Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Encounter > New or Open Note button > CC/HPI/ROS

The CC/HPI/ROS window is where you enter the chief complaint, history of present illness, and review of systems.

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.

Patient Encounter: CC/HPI/ROS Map

Number
SectionDescription

1

CC/HPI/ROS buttonThe CC/HPI/ROS button opens the CC/HPI/ROS window in the patient's encounter note.
2
Encounter Function buttonsThe Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.
3
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
4
All TemplatesThe All Templates field is used to select an encounter template that was created or edited in the Encounter Template Editor. Predefined information will appear in the encounter when a template is selected.
5
Complete List buttonThe Complete List button provides a complete list of encounter templates.
6
Prior Notes buttonThe Prior Notes button views prior notes and messages for the selected patient.
7
Chief Complaint (CC), History of Present Illness (HPI), and section controls
  • Chief Complaint (CC): The CC field is a text box where you can enter the reason for the visit. This field auto-populates if a symptom template is applied.
  • History of Present Illness (HPI): The HPI fields allow you to document the patient's HPI using drop-downs for: location, timing/onset of symptoms, duration, and severity. The text box allow you to enter additional information not available in the drop-down menu.
  • CC/HPI Controls:
    • + CC/HPI: Creates an additional CC/HPI entry for the patient's Encounter. If additional CC/HPIs are added, each is grouped together in the Visit Summary.
    • Delete: Deletes the CC/HPI information that is displayed.
    • < Toggle Button >: Active when more than one CC/HPI has been entered. This gives the user the ability to focus on documenting one CC/HPI at a time.
  • Phrase Construction is available in both the CC and HPI sections of the Encounter.  
8
Review of Systems (ROS)The ROS fields is where you can assess and document the patient's symptoms categorized by body systems.  Under each system, various systems 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.
9
Custom QuestionThe Custom Question field adds a custom question to a selected category in Patient Encounter ROS list.
Version 20.8

About Patient Encounter: CC/HPI/ROS Tab

Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Encounter > New or Open Note button > CC/HPI/ROS

The Patient Encounter helps to code and complete an encounter visit. The encounter note encompasses both narrative and comprehensive formats. It also allows you to customize the layout of the note. The note is added to the patient chart.

The CC/HPI/ROS window is where you enter the chief complaint, history of present illness, and review of systems.

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.

Patient Encounter: CC/HPI/ROS Tab Map

Number
SectionDescription

1

CC/HPI/ROS buttonThe CC/HPI/ROS button opens the CC/HPI/ROS window in the patient's encounter note.
2
Encounter Function buttonsThe Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.
3
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
4
All TemplatesThe All Templates field is used to select an encounter template that was created or edited in the Encounter Template Editor.  Predefined information will appear in the encounter when a template is selected.
5
Complete List buttonThe Complete List button provides a complete list of encounter templates.
6
Prior Notes buttonThe Prior Notes button views prior notes and messages for the selected patient.
7
Chief Complaint (CC)The CC field is a text box where you can enter the reason for the visit.  
8
History of Present Illness (HPI)The HPI fields allow you to select (drop-down menu) and/or enter (text box) in the History of the Present Illness.  Dropdown fields can include data such as timing of onset of symptoms, duration, severity, location (i.e. left ear).  It also can indicate if the patient had a fever before coming in to the office. Text boxes allow you to enter additional information that is not in the drop-down menu.
9
Review of Systems (ROS)The ROS fields is where you can assess and document the patient's symptoms categorized by body systems.  Under each system, various systems 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.
10
Custom Question
The Custom Question field adds a custom question to a selected category in Patient Encounter ROS list.