HPI

HPI is available in the following encounter types: Exam, Multi-System, Procedure, Reconciliation, Telephone, and Urgent Care.

• The clinical content for the structured HPIs is customizable at the user and CLINIC level. Go to Tools > Preferences > CLINIC or [user] > Clinical Content > Begin Edit and select the HPI category
• Organizational Category favorites for the HPI and Chief Complaint favorites are customizable at the user and CLINIC level. Go to Tools > Preferences > CLINIC or [user] > Form Data > Begin Edit and select History Present Illness from the Tab list
• Structured or Narrative tab default for HPI entry can be set at the user and CLINIC level. Go to Tools > Preferences > CLINIC or [user] > Application Settings
• Narrative HPI display order can be set at the user and CLINIC level. Go to Tools > Preferences > CLINIC or [user] > Application Settings

Sevocity Best Practice

Clinical content should be customized at the CLINIC level and copied to all users at the clinic to ensure consistent documentation in the patient record

1. Go to Encounter > HPI
2. Click Add HPI
3. Optional: Select a chief complaint Category
4. Select a Chief Complaint or click Custom and type a chief complaint in the free text field and click Save
   1. Optional: If using Custom, click Save to Favorites or Save to Favorites and Alphabetize to save the item to the Chief Complaint favorites list for future use
5. From the Structured tab, select all details about the condition reported by the patient
6. Optional: click the Narrative tab and type any additional information not captured in the structured HPI
7. Click OK to add or Add Another to document another HPI

The dynamic display field will display the structured HPI as it is being documented.

1. Go to Encounter > HPI
2. Click Add HPI
3. Optional: Select a chief complaint Category
4. Select a Chief Complaint or click Custom and type a chief complaint in the free text field and click Save
   1. Optional: If using Custom, click Save to Favorites or Save to Favorites and Alphabetize to save the item to the Chief Complaint favorites list for future use
5. Click the Narrative tab
6. Type the details about the condition reported by the patient in the free text field
7. Click OK to add or Add Another to document another HPI

The Last button can be used to populate the current Chief Complaint and HPI with information documented during any of the patient's previous encounters. The last HPI can include a combination of structured and narrative elements.

1. Go to Encounter > HPI
2. Click Last
3. Select the encounter with the HPI to be used
4. Only encounters that are the same Encounter Type as the current visit will display for selection
   1. Optional: click Get Previous 5 HPIs to view more/older encounters
5. After reviewing the previously documented HPI, click Apply to apply all information to the current HPI

Clinic staff can document patient-reported information related to the chief complaint or HPI in the Nursing Note.

1. Go to Encounter > HPI
2. Click Enter Nursing Note
3. Type the details about the condition reported by the patient in the free text field
4. Click OK

The Referral Source should be documented for patients who were referred from another provider or healthcare organization. Referring providers added in this tab will automatically appear in the Carbon Copy tab, if enabled.

To add the referral source used in a previous HPI, click Insert Last. The Referral from field will be populated with the most recently used referral source.

Add a Referral Source from a Contact List

1. Go to Encounter > HPI
2. Click Add/Change Referral
3. Select a contact from the Patient Contacts, User Contacts, or Clinic Contacts list
4. Click Save

Create a Custom Referral Source

1. Go to Encounter > HPI
2. Click Custom
3. Select Person or Business
4. Type person Last Name and First Name or business Name
5. Populate all applicable information fields for the contact
6. Optional: select Add to My Contact List checkbox to create a User Contact from this entry
7. Click Save
8. Select a contact from the Patient Contacts, User Contacts, or Clinic Contacts list
9. Click Save

Transition of Care Checkbox

Select the Encounter Related to Transition of Care into Clinic checkbox if the patient was transitioned to the clinic from another setting of care.

Note

If using the Visit Type of Outpatient Consultation or Inpatient Consultation in the Coding tab, a referral source is required to finalize the encounter