We are now ready to move on to the HPI section. When you see a new patient in our system, they will have a chart that has been prepped by our medical assistant team. This includes the Health Risk Assessment extract, which will look something like this.
At the top of the HPI section, you will see a one-liner summarizing the patient’s information, along with placeholders for who the patient was referred by, who their primary care provider is, and any sub-specialists involved in their care.
You can opt to utilize these placeholders to capture that information, but it’s best practice to enter it directly into the care team section under ‘Primary Care Provider’ in the patient’s information. You can do this by searching for the provider’s name. The same process applies for any sub-specialty care, either choose from the listed options or search for one that isn’t listed.
If you decide to keep the referral information in the placeholders, that’s fine too. For example, you might note that the patient was referred by a friend or a specific primary care provider. If the referral comes from a specific organization, like the State of Connecticut, just populate that field. This helps us understand how the patient came to our practice.
Next, let’s discuss vitals. The chart will include the patient’s height, which is self-reported, as well as a blank weight section. You can delete the blank weight placeholder since we capture weight in the Vitals section. The highest and baseline weights are also self-reported, so you’ll want to confirm this information with the patient during their visit to ensure accuracy.
If there are insufficient readings for blood pressure, that means the patient hasn’t checked their blood pressure or hasn’t recorded it at least three times since starting with us. You can simply leave that section as is without entering any averages