SamNotes Temporary HPI

September 25th, 2018

Summary

This HPI feature introduces a button into the patient SamNotes screen.  This new feature allows a staff member to document the history of the present illness (HPI)  (subjective information) without choosing a diagnosis.  The doctor can then go into the system and associate that "active" HPI to a complaint with either the Podiatry Care Macro (aka Routine Footcare Macro) or the Chief Complaint Macro.  All the HPI's used in the system with a supermacro will also be saved going forward.  The history that is saved will allow us in the future to track certain things like pain for other specific problems.

  1. This feature is accessed through the SamNotes program when the user clicks on the HPI button in the patient screen.

  3. Staff members are now able to document the HPI of a patient without associating it with a chief complaint.
  4. The HPI can be repeated and modified as needed.
  5.  There are two types of HPI's Active HPI's that can be associated with a problem, and previous HPI's - all the HPI's that have been signed/closed when doing a note.


Start a new HPI

Step 1: Click on the HPI button on the patient chart

  • If there are no HPI's then the HPI button will be yellow.  
  • If there are previous HPI's the HPI button will be orange.  
  • If there are active HPI's then the button will be green.

Step 2: If there are no  HPI's then the HPI screen will automatically open for the user to document the HPI.  The complaint now reads: This (year old) (sex) complains of (or depending on settings presents with)   The client is supposed to complete this sentence.  a painful toe

Settings: 

For Chief Complaint to read as presents with:

 

For Routine Foot Care supermacro you need to go into specialty settings and type what you would like

The user will then be able to click on the location, duration etc.  when finished filling this out then click Continue.

Edit/Repeat an Existing HPI

Step 1: Click on the HPI button

Step 2:  If you want to edit an active HPI double click on the entry and you will be able to either edit or repeat it.

If you want to repeat a previous HPI then double click it, change what you would like to and click continue.

Using the HPI in RFC

Step 1: Click on the Template for RFC 

Step 2: You will now be able to view the active HPI's so you can have a educated guess as to what chief complaint you would like to associate with it.

Step 3: Select the complaint, site, attributes, pain and treatment, then you will be brought over the HPI column, when that opens up you will see an empty HPI screen with the temporary HPI that you just viewed.  Click Use to add that HPI to your note.  Then click Continue

Step 4:  Click Continue to complete the note.  

Note: The site in the HPI will no longer be overwritten by the location chosen in the RFC site picker.  

Step 5: Once the note gets to the signing screen and a button click is made there (either sign or close) the HPI will be considered a previous one.