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In Physical Therapy, most chief complaints have 24 different parameters that can be used to document information relevant to the patient's chief complaint. Selecting a symptom, such as pain, can add additional parameter links to the left pane so that the symptom can be documented in greater detail.
The following table defines all of the parameters available for documenting a Physical Therapy dynamic HPI.
| Parameter | Description |
|---|---|
| Intro | Introduction of the patient, with name, age, gender; purpose of this visit, such as evaluation of complaint or follow up. |
| Symptom | Laterality view includes the following with grids for right and left sides separately:
|
| Onset | Non-laterality view, with a single grid to indicate once for both right and left sides, includes a list of onset options to indicate when symptoms or chief complaint began. You can also select the option to free text an entry. |
| Place of injury | Non-laterality view includes the following with a single grid to indicate:
You can also select the option to free text an entry. |
| Mechanism of injury | Non-laterality view, with a single grid to indicate, includes a list of options to indicate the reason of injury. You can also select the option to free text an entry. |
| Frequency | Non-laterality view, with a single grid to indicate; includes a list of options to indicate how often symptoms or the chief complaint occurs. You can also select the option to free text an entry. |
| Status | Non-laterality view, with a single grid to indicate once for both right and left sides; includes a list of options to indicate the status of the symptoms or the chief complaint. You can also select the option to free text an entry. |
| Severity | Non-laterality view, with a single grid to indicate once for both right and left sides; includes a list of options to indicate the severity of the symptoms or the chief complaint. You can also select the option to free text an entry. |
| Quality | Non-laterality view, with a single grid to indicate once for both right and left sides; includes a list of options to indicate the quality of the symptoms or the chief complaint. You can also select the option to free text an entry. |
| Timing | Non-laterality view, with a single grid to indicate once for both right and left sides; includes a list of options to indicate the timing of the symptoms or the chief complaint. You can also select the option to free text an entry. |
| Primary Pain Location | Laterality view, with grids for right and left sides separately; includes a list of body location options to select for primary pain; indicators for indicating which side has greater pain or if both sides are equal. |
| Additional Pain Locations | Laterality view, with grids for right and left sides separately; includes:
|
| Patient Denies Pain | Laterality view, with grids for right and left sides separately; includes:
|
| Best Pain | Non-laterality view, with a single grid to indicate once for both right and left sides; includes a list of options to indicate the best pain level score of the symptoms or the chief complaint from 0/10 through 10/10 |
| Worst Pain | Non-laterality view, with a single grid to indicate once for both right and left sides; includes a list of options to indicate the worst pain level score of the symptoms or the chief complaint from 0/10 through 10/10 |
| Current Pain | Non-laterality view, with a single grid to indicate once for both right and left sides; includes a list of options to indicate the current pain level score of the symptoms or the chief complaint from 0/10 through 10/10 |
| Pain Radiation | Laterality view, with grids for right and left sides separately; includes:
|
| Numbness general location | Laterality view, with grids for right and left sides separately; includes:
|
| Numbness from/to | Laterality view, with grids for right and left sides separately; includes:
|
| Paresthesia general location | Laterality view, with grids for right and left sides separately; includes:
|
| Paresthesia from/to | Laterality view, with grids for right and left sides separately; includes:
|
| Weakness Location | Laterality view, with grids for right and left sides separately; includes:
|
| Deformity | Non-laterality view, with a single grid; includes a list of options to document details of any deformity related to the chief complaint; selections include age at diagnosis, if deformity occurred with onset of puberty, if deformity occurred with onset of menarche (for female patients), how long ago (did deformity begin), and family history of deformity with non-laterality view; Non-laterality view enables you to select the option to free text an entry for certain non-yes/no and non-numeric details. Use left arrow link that appears above the grid to navigate back a step and to return to the main dynamic HPI view for deformity. |
| Aggravated by | Non-laterality view, with a single grid to indicate once for both right and left sides; includes a list of options to indicate that no specific activity aggravates or a list of activities that do aggravate the symptoms or the chief complaint. You can also select the option to free text an entry. |
| Relieved by | Non-laterality view, with a single grid to indicate once for both right and left sides; includes a list of options to indicate that no specific activity relieves or a list of activities that do relieve the symptoms or the chief complaint. You can also select the option to free text an entry. |
| Associated symptoms | Non-laterality view, with a single grid to indicate once; includes a list of options to indicate no associated symptoms or those related to the chief complaint. You can also select the option to free text an entry. |
| Pertinent negatives | Non-laterality view, with a single grid to indicate once; includes a list of options to indicate no pertinent negatives or those related to the chief complaint. You can also select the option to free text an entry. |
| Previous diagnostics | Non-laterality view, with a single grid to indicate once; includes a list of options to document any previous diagnostic studies performed. You can select the study type and then the study or test. You can also select the option to free text an entry. |
| Prior medications | Non-laterality view, with a single grid to indicate once; includes a list of options to indicate any previous medications taken related to the chief complaint; first select the medication classification and then the medication. You can also select the option to free text an entry. |
| Prior injections | Non-laterality view, with a single grid to start; includes a list of options to document details of any previous injections administered to the patient related to the chief complaint; selections include type and location with laterality view, and response to treatment, percent relief, and degree of relief with non-laterality view; can select the option to free text an entry for certain non-numeric details. Use left arrow link that appears above the grid to navigate back a step and to return to the main dynamic HPI view for prior injections. |
| Previous treatment | Non-laterality view, with a single grid; includes a list of options to document details of any previous treatment received by the patient related to the chief complaint; selections include type, response to treatment, percent improvement, and degree of relief with non-laterality view; can select the option to free text an entry for certain non-numeric details. Use left arrow link that appears above the grid to navigate back a step and to return to the main dynamic HPI view for previous treatment. |
| Previous therapy | Non-laterality view, with a single grid; starts with yes or no response; if yes, includes a list of options to document details of any previous therapy received by the patient related to the chief complaint; selections include type, program type, response to treatment, percent improvement, and duration of treatment with non-laterality view; can select the option to free text an entry for certain non-numeric details. Use left arrow link that appears above the grid to navigate back a step and to return to the main dynamic HPI view for previous therapy. |
| Past surgeries | Non-laterality view, with a single grid; includes a list of options to document details of any previous therapy received by the patient related to the chief complaint; selections include surgery (procedure), date of surgery, response to treatment, percent improvement, and duration of improvement with non-laterality view; can select the option to free text an entry for certain non-numeric details. Use left arrow link that appears above the grid to navigate back a step and to return to the main dynamic HPI view for previous surgeries. |
| Previous episodes | Non-laterality view, with a single grid; starts with yes or no response; if yes, includes a list of options to document details of any previous episodes related to the chief complaint; selections include time frame, date, number of previous episodes, and frequency of previous episodes with non-laterality view. Use left arrow link that appears above the grid to navigate back a step and to return to the main Dynamic HPI view for previous episodes. |
| Previous injury | Non-laterality view, with a single grid; starts with yes or no response; if yes, includes a list of options to document details of any previous episodes related to the chief complaint; selections include date and number of previous injuries with non-laterality view. Use left arrow link that appears above the grid to navigate back a step and to return to the main dynamic HPI view for previous episodes. |
| Work status | Non-laterality view, with a single grid to indicate; includes a list of options to indicate work status. You can also select the option to free text an entry. |
| Patient goals | Non-laterality view, with a single grid to indicate; includes a list of options to indicate patient goals; You can also select the option to free text an entry. |