Adding HPI of Patients
You can enter the patient's history of present illness (HPI) on the IORTShpi window.
The following table describes the fields on the IORTShpi window. If you select the option for a field and do not select the appropriate location or applicability, the corresponding item will not be displayed in the office note document.
| Field | Description |
|---|---|
| Pain Location | You can indicate the applicable side of the body, and select the location of pain from the list. You can enter additional values in subsequent fields. |
| Denies Pain | You can indicate the applicable side of the body, and select the body part that denies pain from the list. You can enter additional values in subsequent fields. |
| Pain Radiates to | You can indicate the applicable side of the body, and select the body part that the pain radiates down from the list. You can enter additional values in subsequent fields. |
| PMP | You can click the field, and select the pain level from the list. |
| Pain Diagram Reviewed | You can indicate that the pain diagram is reviewed. |
| Onset | You can click the field, and enter period of onset of the pain from the number pad window. |
| Date | You can click the field, and enter the date of onset from the calendar window. |
| Injury | You can indicate that the pain is due to an injury, and enter the date of injury. |
| Description | You can click the field, and enter the description of pain from the description window. |
| Description Questions | You can click the field, enter the question for pain from the description window, and then indicate the applicability of the selected question. |
| Timeframe | You can click the field, enter the question about the timeframe from the duration window, and then enter duration from the number pad window. |
| Severity | You can indicate the severity of the pain. |
| Pain Scale | You can enter the current, lowest, and highest pain scales from one to ten from the corresponding lists. You can also indicate which side of the body has the highest pain. |
| Status | You can click the field, select the percentage of the pain status, and then indicate one of the following for the pain status.
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| Timeframe | You can click the field, and enter duration from the number pad window. |
| Quality | You can indicate qualities of pain. |
| Timing | You can click the field, select the question for the timing of pain from the timing window, and then indicate the applicability. You can also enter additional values in subsequent fields. |
| Associated Symptoms | You can click the field, select the question for the symptoms of pain from the symptom window, and then indicate the applicability. You can also enter additional values in subsequent fields. |
| Context | You can click the field, select the question for the context from the context window, and then indicate the applicability. You can also enter additional values in subsequent fields. |
| Modifying Factors General | You can click the field, select the modifying factor of pain from the modify window, and then select the effect of the factor from the list. You can also enter additional values in subsequent fields. |
| Previous Meds | You can document the previous medications tried by the patient and the effect of each medication on the IORTShpi Prevmeds window. |
| Previous Non-op Treatment | You can click the field, select the non-operative treatment provided to the patient from the treatment window, and then select the effect of the treatment from the list. In the corresponding # and Previous Provider fields, you can enter the number of previous treatments and provider of the treatment. You can also enter additional values in subsequent fields. |
| Previous Procedures | You can select the procedure performed for the patient from the procedures window, and select the effect of the procedure from the list. In the corresponding # and Previous Provider fields, you can enter the number of previous procedures and who has performed the procedure. You can also enter additional values in subsequent fields. |
| Previous Surgeries | You can click the field, and select the surgeries performed for the patient from the surgeries window. In the corresponding Comments/Complications field, you can select the effect of the surgery from the list and enter any additional comments. You can also enter additional values in subsequent fields. |