Encounter HPI
Source Object: Encounter HPI (History of Present Illness)
Overview and Usage: The "Encounter HPI" source object in athena EHR is instrumental for capturing and managing the History of Present Illness (HPI) during patient encounters. It allows healthcare providers to record details about a patient's current medical condition, including symptoms, duration, and other relevant information. Here's an overview of key fields and their usage:
- HPI: "HPI" contains the patient's history of present illness, documenting the details provided by the patient regarding their current medical condition. This includes symptoms, their onset, and other relevant factors.
- HPI to ROS: "hpitoros" may indicate the relationship or connection between the History of Present Illness and Review of Systems (ROS). It helps in understanding how the patient's current condition relates to their broader health.
- HPI to ROS Last Modified By: "hpitoroslastmodifiedby" records the user or entity responsible for the last modification of the connection between HPI and ROS.
- HPI to ROS Last Modified Date and Time: "hpitoroslastmodifieddatetime" indicates the date and time when the connection between HPI and ROS was last modified.
- Last Modified By: "lastmodifiedby" specifies the user or entity responsible for the last modification of the encounter's HPI.
- Last Modified Date and Time: "lastmodifieddatetime" records the date and time when the HPI was last modified, facilitating tracking of changes and updates.
- Section Note: "sectionnote" provides additional notes or comments related to the HPI section, allowing for supplementary information or context.
- Section Note Last Modified By: "sectionnotelastmodifiedby" records the user or entity responsible for the last modification of the section note.
- Section Note Last Modified Date and Time: "sectionnotelastmodifieddatetime" captures the date and time when the section note was last modified.
- Summary Text: "summarytext" may offer a summarized version of the HPI, providing a concise overview of the patient's current medical condition.
- Template Data: "templatedata" can contain structured template data related to the HPI, ensuring consistent and standardized documentation.
- Templates: "templates" indicate the specific templates or forms used for capturing HPI information, which may vary based on clinical specialties or encounter types.
- Replace Section Note: "replacesectionnote" may be used to specify a replacement or updated section note, allowing for the modification of section notes within the HPI.
The "Encounter HPI" source object is vital for healthcare providers to document the history of the present illness during patient encounters. It ensures proper documentation of the patient's medical condition, symptoms, and associated details, which is essential for diagnosis, treatment planning, and care coordination. Developers can utilize this source object to build features and applications that enhance the documentation and management of the HPI within athena EHR.
Mapping Table
| Data Field | Example Value | Source Data Field Description | Source Field Data Type | Source Data Field Cardinality | Mapped FHIR++ Resource | Mapped FHIR Data Field | Augmented Mapping | Associated Coding System | Associated FHIR Data Field Extension | Mapping Context |
|---|---|---|---|---|---|---|---|---|---|---|
| hpi | - | The structured HPI data. It is structured as a list of paragraphs, each containing a list of sentences, each containing a list of findings. | array | 0..1 | Encounter | extension.valueString | hpi | Top Level | ||
| hpitoros | - | Whether ROS is as noted in HPI. | string | 0..1 | Encounter | extension.valueString | hpi-to-ros | Top Level | ||
| hpitoroslastmodifiedby | - | The username of the provider that last modified the hpitoros parameter. | string | 0..1 | Encounter | extension.valueString | hpi-to-ros-last-modified-by | Top Level | ||
| hpitoroslastmodifieddatetime | - | The date and time that the hpitoros field was last modified. | string | 0..1 | Encounter | extension.valueDateTime | hpi-to-ros-last-modified-datetime | Top Level | ||
| lastmodifiedby | - | A string representing the username of the user who last modified the history of present illness section. | string | 0..1 | Encounter | extension.valueString | hpi-last-modified-by | Top Level | ||
| lastmodifieddatetime | - | The last time any information in the history of present illness section was modified. | string | 0..1 | Encounter | extension.valueDateTime | hpi-last-modified-datetime | Top Level | ||
| sectionnote | - | The structured section-level note for the history of present illness section. | string | 0..1 | Encounter | extension.valueString | hpi-section-note | Top Level | ||
| sectionnotelastmodifiedby | - | A string representing the username of a the user who last modified the history of present illness section note. | string | 0..1 | Encounter | extension.valueString | hpi-section-note-last-modified-by | Top Level | ||
| sectionnotelastmodifieddatetime | - | The last time the history of present illness section note was modified. | string | 0..1 | Encounter | extension.valueDateTime | hpi-section-note-last-modified-datetime | Top Level | ||
| summarytext | - | The unstructured summary. | string | 0..1 | Encounter | extension.valueString | hpi-summary-text | Top Level | ||
| templatedata | - | An array of objects each containing the names, ids and notes for templates attached to the encounter. | array | 0..1 | Encounter | extension.valueString | hpi-template-data | Top Level | ||
| templates | - | The comma separated list of selected HPI templates used. | string | 0..1 | Encounter | extension.valueString | hpi-templates | Top Level | ||
| replacesectionnote | - | If true, will replace the existing section note with the new one. If false, will append to the existing note. | boolean | 0..1 | Encounter | extension.valueBoolean | hpi-replace-section-note | Top Level |