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Enter the History of Present Illness (HPI)

Q: How do I enter the history of present illness (HPI)?

1. Open the SOAPnote

Open an existing SOAPnote or create a new SOAPnote.  

See: Create a SOAPnote for help.

2. Place Cursor into Subjective Field

2. Place Cursor into Subjective Field

Place your cursor into the Subjective field of the SOAPnote, under the Chief Complaint.  The bold green brackets indicate that the field is active and you can begin entering documentation.

3. Enter HPI Pick List

3. Enter HPI Pick List
  1. Type the shortcut code "HPIss"
  2. With the cursor directly behind the "s", press Shift + F11
  3. Double-click on the item named "(HPI - Starter/Spaced) (Feb 09)" with a green downward facing arrow

4. Select Reports/Denies Sub-Items

4. Select Reports/Denies Sub-Items
  1. Click on the SYMPTOMS/RELATED pick list
  2. Select the "Denies symptoms of" sub-item if desired from the SMARText Quick Access window

Repeat this step for each of the pick lists, to select "Reports" or "Denies" (or other options) as desired:

  • LOCATION
  • QUALITY/COURSE
  • INTENSITY/SEVERITY
  • DURATION
  • ONSET/TIMING
  • CONTEXT/WHEN
  • MODIFIERS/TREATMENTS

5. Enter HPI

5. Enter HPI
  1. Click on the "Reports symptoms of" pick list located behind SYMPTOMS/RELATED.  This will display a list of common symptoms that can be checked as "Reports" or "Denies".
  2. Using the SMARText Quick Access window, place a check in the box for any symptoms reported or denied

Repeat this step for each of the pick lists, to enter the HPI:

  • LOCATION
  • QUALITY/COURSE
  • INTENSITY/SEVERITY
  • DURATION
  • ONSET/TIMING
  • CONTEXT/WHEN
  • MODIFIERS/TREATMENTS

After repeating the steps above, the HPI will be completed.

6. Remove Unused Items

6. Remove Unused Items

To remove any pick lists that were not used:

  1. Right click on the Subjective header
  2. Select Remove Unused Items

7. Completed HPI

7. Completed HPI

The HPI has been completed and all unused pick lists have been removed.

How Do I... Video

The above video will demonstrate the steps required to complete the Chief Complaint, HPI and ROS in SOAPware.  Click the Play button to begin the video.

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