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Uti_hpi_sample

UTI, Acute
Specialty: Family Practice
Category: Family Practice
Related Content:

History of Present Illness
Reason for Visit:
Problem (Visit Type)
Priority: 1
Visit Type
Menu Type: Single
Sentence: The patient is being seen for
Display Text
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an initial evaluation of an acute urinary tract infection follow-up of an acute urinary tract infection follow-up of a hospitalization for an acute urinary follow-up from a previous urgent care visit for an follow-up from an emergency room visit for an acute worsening symptoms of an acute urinary tract Symptoms:
Symptoms
Priority: 1
Symptoms
Menu Type: YesNo
EMCODE: Associated Signs and Symptoms
Yes Sentence: Symptoms include
No Sentence: Symptoms do not include Display Text
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Pain Location
Menu Type: Multiple
EMCODE: Location
Sentence: The pain is located in the
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Radiation
Menu Type: Multiple
EMCODE: LocationSentence: The pain radiates to the Display Text
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Pain Quality
Menu Type: Multiple
EMCODE: Quality
Sentence: The patient describes the pain as
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Onset Mode
Menu Type: Single
EMCODE: Timing
Sentence: Onset was
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Onset
Menu Type: Single
EMCODE: Duration
Sentence: Symptoms began
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Timing
Menu Type: Multiple
EMCODE: Timing
Sentence: The symptoms occur
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Current Symptom Frequency
Menu Type: Single
EMCODE: Timing
Sentence: Currently, the symptoms occur Display Text
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Current Symptom Duration
Menu Type: Single
EMCODE: Duration
Sentence: The symptoms last for
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Severity
Menu Type: Single
EMCODE: Severity
Sentence: The patient describes the symptoms as
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Progression
Menu Type: Single
EMCODE: Severity
Sentence: The symptoms are
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Exacerbating Factors
Menu Type: YesNo
EMCODE: Modifying Factors
Yes Sentence: Symptoms are exacerbated by
No Sentence: Symptoms are not exacerbated by
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Relieving Factors
Menu Type: YesNo
EMCODE: Modifying Factors
Yes Sentence: Symptoms are relieved by
No Sentence: Symptoms are not relieved by
Display Text
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Current Treatment:
Current Treatment
Priority: 1
Current Treatment
Menu Type: Multiple
EMCODE: Modifying Factors
Sentence: Current treatment includes
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Adherence/Tolerance/Control
Menu Type: Multiple
EMCODE: Modifying Factors
Sentence: By report, there is
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Pertinent History:
Pertinent Medical History
Priority: 1
First Episode
Menu Type: Single
EMCODE: Duration
Sentence: The first urinary tract infection occurred
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UTI Frequency
Menu Type: Multiple
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urinary tract infections in the past six months urinary tract infections in the past year Pertinent Medical History
Menu Type: YesNo
Yes Sentence: Pertinent medical history includes No Sentence: Pertinent medical history does not
include
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Risk Factors
Menu Type: YesNo
Yes Sentence: Risk factors include
No Sentence: Risk factors do not include
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Evaluation and Treatment History:
Eval/Diagnosis History
Priority: 1
Prev Evaluation Setting
Menu Type: Single
EMCODE: Modifying Factors
Sentence: The patient was previously evaluated
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Prev Evaluation Timing
Menu Type: Single
EMCODE: Duration
Sentence: The previous evaluation took place
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Presentation
Menu Type: Multiple
Sentence: Previous presentation included
Past Evaluation
Past Evaluation
Menu Type: Multiple
Sentence: Past evaluation has included
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Treatment History
Past Treatment
Menu Type: Multiple
Sentence: Past treatment has included
Display Text
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Pty

Source: https://health-e-decisions.googlecode.com/svn/trunk/src/examples/UTI_HPI_Sample.pdf

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