HPI
The acronym for details to be included in the HPI
LOCATES
What to document in ROS
What pt endorses/denies
Billing requirement
How to find chart review
Ask the physician
Abbreviation for patient
Pt
The only thing clicked in the HPI form, unless provider says otherwise
"History provided by..."
System where you document dizziness
Neurological
How to document region of abdominal pain
Under the Abd tab
How to find differentials
IVF (in ER context)
IV fluids
First sentence of the HPI
Initial evaluation performed by Dr. X at TIME
What system to document fever
Constitutional
System where you document diaphoresis
Constitutional
How to document an ultrasound performed
Timestamp
r/o
rule out
Chief complaint often heard for vertigo
Dizziness
How to leave a comment on a clickable
Hover and type OR double click
How to document patient in mild distress
Comment on acute distress
How to tell if a lab is notable
Ask physician
NPO
3 things usually asked for social history
How you would document bloody cough
Comment in respiratory
System where you would document positive straight leg raise
Musculoskeletal
How to find plan of care (irl)
Order Review tab or Workup tab
DKA
Diabetic ketoacidosis