- Open the Intake template and enter a Specialty and Visit Type.
Enter Physical Therapy for the Specialty and Physical therapy evaluation for the Visit Type.
- In the Reason for Visit panel on the Objective tab, do one of the following to open the corresponding HPI template:
- If no Reason for Visit was entered during the intake process, select a reason for visit value (for example, elbow) .
- If a Reason for Visit appears in the grid, click the desired row.
In other specialties, the Reason for Visit panel is also available on the SOAP tab.
At the top of the dynamic HPI template, a ribbon field appears with any other documented reasons.
- To change the Reason on the dynamic HPI template, do one of the following:
- Click the blue arrow next to the Reason field to select a value from the list.
- In the top ribbon, click the arrow to toggle and select a previously documented reason and move that value to the Reason field.
- Click intro in the left pane.
Each reason includes an intro. The options available for the introductory text varies based on the chosen Reason. The selections available to dynamically build the historical note are different for each Reason.
- In the intro field, click name, age, gender to fill the concatenation grid with the patient’s information.
An asterisk next to the section indicates that has been it is added to the concatenation. The selected data also fills in the History of Present Illness column on the shared grid that appears on both the HPI and SOAP templates.
- In the intro grid, click complains to add “who complains of” to the concatenation.
- If appropriate, at any time you can select one of the following options:
- Right greater than Left
- Right
- Right equals Left
- Left
- Left greater than Right
- Click another section, for example, symptom, to reveal the lateral (for example, Right and Left) findings on the dynamic template.
- Click a finding from the lateral options as appropriate.
The Chief Complaint grid can include free text an entry as an option. When you select free text an entry, a template appears to enable you add additional information to the concatenation.
- Click another section to continue building the HPI based on the available findings for that section.
The field at the bottom of the dynamic template populates with the concatenated note.
- Repeat the selections until the history is complete.
The concatenation functionality is set up so that you do not have to select every section or finding. You can skip sections that are not needed. There are no rules pertaining to the order of selection or the amount of data that can be included.
- Click the Close button.
