About Patient Encounter: CC/HPI/ROS Tab
Path: Smart Toolbar > Chart button > Encounters tab > Open Note > CC/HPI/ROS tab
Path: Smart Toolbar > Schedule Button > Encounters tab > Edit button > CC/HPI/ROS tab
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 tab 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
|Encounter Note Editor tabs|
The Patient Encounter Note Editor contains the following tabs:
|Care Plans tab||The Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule.|
|Visit Date||The Visit date field indicates the date that the patient encounter occured.|
|Prior Notes tab||The Prior Notes tab lists the previous encounter notes and messages.|
The Templates tab lists the templates that are created, edited, and reviewed in the Encounter Templates Editor. Templates are pre-written scenarios you can use in an encounter to document common pediatric diagnoses. Templates include detailed descriptions for the usual pertinent positive and negative findings of a wide variety of illnesses, with a standard assessment, plan and ICD-10 coding. Included with your installation of Office Practicum are Pediatric specific templates.
|All Templates||The 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.|
|Function buttons||The Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.|
|Flag as Incomplete checkbox||The Flag as Incomplete checkbox will mark an encounter as unfinished.|
|Chief Complaint (CC)||The CC field is a text box where you can type in the reason for the visit. You can free Type in the box. You can also delete any text from the box.|
|History of Present Illness (HPI)|
The HPI fields allow you to select (dropdown fields) and/or type (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 part of the dropdown selection.
|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.|
|Custom Question||The Custom Question field adds a custom question to a selected category in Patient Encounter ROS list.|