Document HPI for Fracture Care

You can document the history of the present illness (HPI) for fracture care.

1. On the appropriate fracture care template, in the History panel, enter the patient's chief complaint, and then click HPI.
   The IORTShpi Fx template opens displaying the chief complaint in the CC field.

   

   Note: The Outside Diagnostic Studies section displays the details documented on the Intake template. You can add or edit the data in this section.
2. Enter the date of injury.
3. In Body Area, indicate which side of the body is injured, click the blank field, and then select the injured body part from the list.
4. To describe the injury, select the appropriate options from the following:
   • Pain. You can click the Level field, and select the pain level from the list.
   • Swelling.
   • Deformity.
   • Numbness, Tingling. You can enter the details of the numbness and tingling in the blank field.
   • Weakness.
5. In the Mechanism of Injury section, if the injury is due to the fall on the outstretched hand, select the Fall On Outstretched Hand check box.
6. Indicate how the patient was injured.
   • If the patient fell from a place or object, click the Fall from field, and select the appropriate option from the list.
   • If the patient was injured while playing a sport, click the Injured playing field, and select the sport on the sports window.
   • If the patient was injured while travelling, click the Vehicle field, and select the vehicle from the list. To indicate if the patient was driving and restrained, select the appropriate options below Vehicle.
   • If the injury was due to any other mechanisms, type the details in the Other Mechanism field.
7. Indicate if the fracture is open or closed.
8. Select the appropriate option in the Where it Happened section.
   Note: If you select the Other option, describe where the patient was injured in the blank field.
9. Select the appropriate option for the initial evaluation.
10. Select the appropriate options for the initial treatment given.
    Note: Type any additional details of the treatment in the blank field.
11. Indicate the dominant hand of the patient.
12. Click Add below the Employer field to add details of the patient's employer.
13. Add the sports details and hobbies of the patient.
14. Click Save & Close.