Recording History of Present Illness (HPI) Information

  1. Click the Chief Complaint tab on the ExamWRITER chart window.
  2. Click the History of Present Illness (HPI) bar.
  3. The History of Present Illness window opens.
    • Select the ALL OK (Except) check box and any appropriate Triage, VisionComplaints, Symptoms, and Progress HPI check boxes.
    • Select the Triage, VisionComplaints, Symptoms, and Progress HPI check box(es) only if there are exceptions to the patient’s healthy medical history; otherwise, only select the ALL OK (Except) check box.
    • Blue text is a heading for the black or red text below it.
    • Red text signifies that the corresponding check box has been previously selected and information relating to that text has been previously recorded.
  4. Click Process or right-click anywhere in the History of Present Illness window.

    Depending on the boxes that you checked, various windows will open with additional check boxes.

  5. If you are documenting ocular complaints, follow the instructions in the drop-down below.

    6. If you select the Common Ocular Complaints check box and you are using the HPI Wizard, follow the instructions below to document the ocular complaints. To turn on the HPI Wizard and make the technician’s job of documenting complaints worry-free, see To set up general preferences.
    1. Search for and select a complaint in the box on the left side of the window (press the F12 key to add a complaint to the box).
    2. Select an eye from the Eye drop-down menu.
    3. In the Keyword and Long Description text boxes, left-click to select the appropriate items from the drop-down menu list and then right-click to save your selections. To modify or add keywords and long descriptions, left-click in a Keyword text box and press the F12 key.
    4. If you prefer to add custom text instead of using the HPI Wizard, click the Custom Text button and type the text in the Custom text box.
    5. Click Save Item to add the complaint to the Ocular Complaint table at the bottom of the window. To edit a saved complaint, click Edit and modify the text. To delete all complaints, click Delete All; or, to delete one complaint, select it and click Delete Item.
    6. After you have finished documenting all ocular complaints, click Process.

    7. Select or deselect the appropriate check boxes and click Process.

In addition to the procedures above, watch this video.