The Patient takes an appointment for a complaint
mentioned in brief and in layman’s terms. During HPI he is likely to elaborate
with a lot more problems. Many may imply the same problem to a Doctor.
The Doctor needs to list out all the Complaints and attend to them in a
systematic manner. The complaints will depend on the specialty of the Doctor,
and a list of complaints can be made here. Besides noting the complaint
the Doctor needs to ask valid questions relevant to the complaint.
The HPI
templates also defined under Configuration option, provides defining a
set of question/tests/elements under a User defined template. This options
provides associating a Template with a complaint. Also the default diagnostic
ICD Code for the complaint is to be defined. Note that more than one complaint
can refer to the same Template.
One template having elements like Location / Severity / Quality can be relevant
to both headaches, as well as back aches. Once this master is defined, during
an encounter the Doctor needs to select a Complaint, and all questions within
the associated template will pop up, and the Assessment will have the associated
ICD codes assigned by default.
The Assessment and Plan notes can be predefined for a particular ICD code associated to a complaint. The complaint when selected by a user in an encounter has the associated ICD code, assessment, and plan notes directly added to the encounter.
While it is necessary to have one HPI template associated with the complaint,
the user may associate, if required, a ROS, Physical , Specialty and Social
History template with the Complaint. |